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Submitted URL: http://go.pardot.com/e/879782/24-utm-content-body-text-link1/5pdz7/1142681781/h/G-7puZZ-oi3Z1qh9hquCk-nGCR3smZtT5jlVP...
Effective URL: https://give.epilepsy.com/page/65175/donate/1?utm_medium=email&utm_source=pardot&utm_campaign=apr24em_f_4a2_matching-gift-...
Submission: On April 27 via api from BE — Scanned from DE
Effective URL: https://give.epilepsy.com/page/65175/donate/1?utm_medium=email&utm_source=pardot&utm_campaign=apr24em_f_4a2_matching-gift-...
Submission: On April 27 via api from BE — Scanned from DE
Form analysis
1 forms found in the DOMName: pb_EMF0424MatchingGiftAPR24 — POST /page/65175/donate/2
<form method="post" id="pb_65175" name="pb_EMF0424MatchingGiftAPR24" action="/page/65175/donate/2" class="en__component en__component--page">
<input type="hidden" name="hidden" class="en__hiddenFields"
value="transaction.othamt3,transaction.honname,transaction.infname,transaction.infemail,transaction.infadd1,transaction.infcity,transaction.infreg,transaction.infpostcd,transaction.gftrsn,,,transaction.othamt2">
<input type="hidden" name="sessionId" value="d348d37ddab44d6295371b6c6e474ec6-use2-prd-web2">
<input type="hidden" name="gatewaytype" value="Stripe Gateway">
<input type="hidden" name="gatewaykey" value="pk_live_51H3L9vEh71zMukUlZ51TUkmQd8PNvOO70RjDaSQMwOlliAZ5S5YtRgtuzSmKIvxRj0LcDai2JbugPEC8y5ypgADa00H85wPNhq">
<input type="hidden" name="gatewayaccountid" value="acct_1BfvB1JP6abHUMAr">
<input type="hidden" name="gatewaymode" value="LIVE">
<ul class="en__errorList">
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<div class="en__component en__component--row en__component--row--1">
<div class="en__component en__component en__component--column en__component--column--1">
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<div class="en__component en__component--row en__component--row--1">
<div class="en__component en__component en__component--column en__component--column--1">
<div class="en__component en__component--copyblock" style="
">
<div class="subtxt-" style="text-align: center; width: 100%; display: block; margin:auto;" width="70%"><span color="#000000" style="font-size:26px; line-height:31px; color:#000000;"><span style="color:#000000; font-weight: bold;">DOUBLE YOUR
DONATION FOR EPILEPSY CARE, ADVOCACY, RESEARCH AND EDUCATION.</span></span></div>
</div>
</div>
</div>
<div class="en__component en__component--row en__component--row--1">
<div class="en__component en__component en__component--column">
<div class="en__component en__component--formblock" style="">
<div class="en__field en__field--radio en__field--withOther en__field--841573 en__field--donationAmt en__mandatory">
<label class="en__field__label" style=""><span data-token="amount-total">$50.00</span></label>
<div class="en__field__element en__field__element--radio
">
<div class="en__field__item">
<input type="radio" class="en__field__input en__field__input--radio" value="35" name="transaction.donationAmt" id="en__field_transaction_donationAmt0">
<label class="en__field__label en__field__label--item" for="en__field_transaction_donationAmt0">$35=$70</label>
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<div class="en__field__item">
<input checked="" type="radio" class="en__field__input en__field__input--radio" value="50" name="transaction.donationAmt" id="en__field_transaction_donationAmt1">
<label class="en__field__label en__field__label--item" for="en__field_transaction_donationAmt1">$50=$100</label>
</div>
<div class="en__field__item">
<input type="radio" class="en__field__input en__field__input--radio" value="100" name="transaction.donationAmt" id="en__field_transaction_donationAmt2">
<label class="en__field__label en__field__label--item" for="en__field_transaction_donationAmt2">$100=$200</label>
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<div class="en__field__item">
<input type="radio" class="en__field__input en__field__input--radio" value="250" name="transaction.donationAmt" id="en__field_transaction_donationAmt3">
<label class="en__field__label en__field__label--item" for="en__field_transaction_donationAmt3">$250=$500</label>
</div>
<div class="en__field__item">
<input type="radio" class="en__field__input en__field__input--radio" value="500" name="transaction.donationAmt" id="en__field_transaction_donationAmt4">
<label class="en__field__label en__field__label--item" for="en__field_transaction_donationAmt4">$500=$1,000</label>
</div>
<div class="en__field__item">
<input type="radio" class="en__field__input en__field__input--radio" value="other" name="transaction.donationAmt" id="en__field_transaction_donationAmt5">
<label class="en__field__label en__field__label--item" for="en__field_transaction_donationAmt5">other</label>
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<div class="en__field__item en__field__item--other en__field__item--hidden">
<input class="en__field__input en__field__input--other" type="text" name="transaction.donationAmt.other" value="">
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<div class="en__field en__field--checkbox en__field--841561 en__field--recurrpay">
<div class="en__field__element en__field__element--checkbox
">
<div class="en__field__item">
<input id="en__field_transaction_recurrpay" type="checkbox" class="en__field__input en__field__input--checkbox" value="Y" name="transaction.recurrpay">
<label for="en__field_transaction_recurrpay" class="en__field__label en__field__label--item">Make this a monthly donation</label>
</div>
</div>
</div>
<input type="hidden" class="en__field__input en__field__input--hidden" name="transaction.recurrfreq" value="MONTHLY">
<input type="hidden" class="en__field__input en__field__input--hidden" name="transaction.recurrday" value="">
<div class="en__field en__field--text en__field--841562 en__field--paycurrency en__mandatory">
<label for="en__field_transaction_paycurrency" class="en__field__label" style="">Payment Currency</label>
<div class="en__field__element en__field__element--text">
<input id="en__field_transaction_paycurrency" type="text" class="en__field__input en__field__input--text" name="transaction.paycurrency" value="USD">
</div>
</div>
<div class="en__field en__field--email en__field--841565 en__field--emailAddress en__mandatory">
<label for="en__field_supporter_emailAddress" class="en__field__label" style="">Email Address for Your Electronic Receipt</label>
<div class="en__field__element en__field__element--email">
<input id="en__field_supporter_emailAddress" type="email" autocomplete="email" class="en__field__input en__field__input--email" name="supporter.emailAddress" value="" placeholder="Enter your email address">
</div>
</div>
<div class="en__component en__component--dd360search">
<p>Many companies sponsor matching gift programs that increase the impact of your gift. See if your company will match your donation! (Optional)</p>
<div id="dd-company-name-input" data-doublethedonation-widget-id="G__2">
<div class="dtd-streamlined-plugin"><input type="hidden" name="doubledonation_status" value="no_interaction"><input type="hidden" name="doublethedonation_status" value="no_interaction"><input type="hidden"
name="doublethedonation_entered_text"><input type="hidden" name="doubledonation_company_id"><input type="hidden" name="doublethedonation_company_id"><input type="hidden" name="doubledonation_company_name"><input type="hidden"
name="doublethedonation_company_name">
<div class="dtd-search-box" style="width: 100%; margin-bottom: 0px;">
<div aria-live="assertive" style="display: block; font-size: 0px; color: rgb(255, 255, 255); opacity: 0; position: absolute; height: 0px; margin: 0px; z-index: -99999;"></div>
<div aria-live="polite" style="display: block; font-size: 0px; color: rgb(255, 255, 255); opacity: 0; position: absolute; height: 0px; margin: 0px; z-index: -99999;"></div><input role="combobox" aria-expanded="false"
name="doublethedonation_company_name_input" autocomplete="new-password" type="text" id="dd-input" class="dtd-search-input form-control BBFormTextbox" placeholder="Search for company..." aria-label="Search for company..."
style="width: 100%;">
</div>
</div>
</div>
</div><input type="hidden" class="en__field__input--hidden" name="supporter.sendOffset" value="+02:00">
<div class="en__field en__field--checkbox en__field--841588 en__field--inmem">
<div class="en__field__element en__field__element--checkbox
">
<div class="en__field__item">
<input id="en__field_transaction_inmem" type="checkbox" class="en__field__input en__field__input--checkbox" value="Y" name="transaction.inmem">
<label for="en__field_transaction_inmem" class="en__field__label en__field__label--item">This gift is in honor of / in memory of (optional)</label>
</div>
</div>
</div>
<div class="en__field en__field--select en__field--841591 en__field--othamt3 en__mandatory en__hidden">
<label for="en__field_transaction_othamt3" class="en__field__label" style="">Is this in honor of or in memory of?</label>
<div class="en__field__element en__field__element--select">
<select id="en__field_transaction_othamt3" class="en__field__input en__field__input--select" name="transaction.othamt3" disabled="">
<option selected="selected" value="InHnr">In Honor Of</option>
<option value="InMry">In Memory Of</option>
</select>
</div>
</div>
<div class="en__field en__field--text en__field--841584 en__field--honname en__mandatory en__hidden">
<label for="en__field_transaction_honname" class="en__field__label" style="">Honoree Name</label>
<div class="en__field__element en__field__element--text">
<input id="en__field_transaction_honname" type="text" class="en__field__input en__field__input--text" name="transaction.honname" value="" disabled="">
</div>
</div>
<div class="en__field en__field--text en__field--841585 en__field--infname en__hidden">
<label for="en__field_transaction_infname" class="en__field__label" style="">Notification Recipient Name </label>
<div class="en__field__element en__field__element--text">
<input id="en__field_transaction_infname" type="text" class="en__field__input en__field__input--text" name="transaction.infname" value="" disabled="">
</div>
</div>
<div class="en__field en__field--text en__field--841576 en__field--infemail en__hidden">
<label for="en__field_transaction_infemail" class="en__field__label" style="">Recipient E-mail Address</label>
<div class="en__field__element en__field__element--text">
<input id="en__field_transaction_infemail" type="text" class="en__field__input en__field__input--text" name="transaction.infemail" value="" disabled="">
</div>
</div>
<div class="en__field en__field--text en__field--841567 en__field--infadd1 en__hidden">
<label for="en__field_transaction_infadd1" class="en__field__label" style="">Notification Recipient Address</label>
<div class="en__field__element en__field__element--text">
<input id="en__field_transaction_infadd1" type="text" class="en__field__input en__field__input--text" name="transaction.infadd1" value="" disabled="">
</div>
</div>
<div class="en__field en__field--text en__field--841577 en__field--infcity en__hidden">
<label for="en__field_transaction_infcity" class="en__field__label" style="">Notification Recipient City </label>
<div class="en__field__element en__field__element--text">
<input id="en__field_transaction_infcity" type="text" class="en__field__input en__field__input--text" name="transaction.infcity" value="" disabled="">
</div>
</div>
<div class="en__field en__field--select en__field--841575 en__field--infreg en__hidden">
<label for="en__field_transaction_infreg" class="en__field__label" style="">Notification Recipient State</label>
<div class="en__field__element en__field__element--select">
<select id="en__field_transaction_infreg" class="en__field__input en__field__input--select" name="transaction.infreg" disabled="">
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
</div>
</div>
<div class="en__field en__field--text en__field--841581 en__field--infpostcd en__hidden">
<label for="en__field_transaction_infpostcd" class="en__field__label" style="">Notification Recipient Zip Code</label>
<div class="en__field__element en__field__element--text">
<input id="en__field_transaction_infpostcd" type="text" class="en__field__input en__field__input--text" name="transaction.infpostcd" value="" disabled="">
</div>
</div>
<div class="en__field en__field--text en__field--841579 en__field--gftrsn en__hidden">
<label for="en__field_transaction_gftrsn" class="en__field__label" style="">Special Message (optional) </label>
<div class="en__field__element en__field__element--text">
<input id="en__field_transaction_gftrsn" type="text" class="en__field__input en__field__input--text" name="transaction.gftrsn" value="" disabled="">
</div>
</div>
<div class="en__field en__field--checkbox en__field--841578 en__field--othamt1">
<div class="en__field__element en__field__element--checkbox
">
<div class="en__field__item">
<input id="en__field_transaction_othamt1" type="checkbox" class="en__field__input en__field__input--checkbox" value="Y" name="transaction.othamt1">
<label for="en__field_transaction_othamt1" class="en__field__label en__field__label--item">I am making a gift on behalf of my company</label>
</div>
</div>
</div>
<div class="en__field en__field--text en__field--841583 en__field--othamt2 en__mandatory en__hidden">
<label for="en__field_transaction_othamt2" class="en__field__label" style="">Company name</label>
<div class="en__field__element en__field__element--text">
<input id="en__field_transaction_othamt2" type="text" class="en__field__input en__field__input--text" name="transaction.othamt2" value="" disabled="">
</div>
</div>
<div class="en__submit"><button style="">Proceed to Pay</button></div>
</div>
</div>
</div>
<div class="en__component en__component--row en__component--row--2">
<div class="en__component en__component en__component--column en__component--column--1">
</div>
<div class="en__component en__component en__component--column en__component--column--2">
</div>
</div>
<div class="en__component en__component--row en__component--row--1">
<div class="en__component en__component en__component--column en__component--column--1">
</div>
</div>
<input type="hidden" name="doublethedonation_key" class="en__field__input en__field__input--hidden" value="fqw9ve0qgsPKJ4B4">
</form>
Text Content
DOUBLE YOUR DONATION FOR EPILEPSY CARE, ADVOCACY, RESEARCH AND EDUCATION. $50.00 $35=$70 $50=$100 $100=$200 $250=$500 $500=$1,000 other Make this a monthly donation Payment Currency Email Address for Your Electronic Receipt Many companies sponsor matching gift programs that increase the impact of your gift. See if your company will match your donation! (Optional) This gift is in honor of / in memory of (optional) Is this in honor of or in memory of? In Honor Of In Memory Of Honoree Name Notification Recipient Name Recipient E-mail Address Notification Recipient Address Notification Recipient City Notification Recipient State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Notification Recipient Zip Code Special Message (optional) I am making a gift on behalf of my company Company name Proceed to Pay © 2021 Epilepsy Foundation®, is a non-profit organization with a 501(c)(3) tax-exempt status. * Privacy * Contact * www.epilepsy.com * Other Ways to Give CONTACT US Headquarters Address: Epilepsy Foundation 3540 Crain Highway Ste 675, Bowie, MD 20716 Phone: 1-800-332-1000 Email: contactus@efa.org FOLLOW US * Facebook * Twitter