secure3.convio.net
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74.123.154.146
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Submitted URL: https://secure3.convio.net/prkorg/site/R?i=XE8u6lm1EtzzgimMocVOLLKVY3MA3udrMJ6QNNEH70N5-ipzO7NHbg
Effective URL: https://secure3.convio.net/prkorg/site/Donation2?12151.donation=form1&df_id=12151&mfc_pref=T
Submission: On November 30 via manual from US — Scanned from DE
Effective URL: https://secure3.convio.net/prkorg/site/Donation2?12151.donation=form1&df_id=12151&mfc_pref=T
Submission: On November 30 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: process — POST https://secure3.convio.net/prkorg/site/Donation2
<form name="process" id="ProcessForm" action="https://secure3.convio.net/prkorg/site/Donation2" method="post" onsubmit="return checkDoubleClick();">
<div class="donation-form-container responsive">
<script type="text/javascript">
<!--
function reloadPage() {
window.location.reload(true);
}
function testAjax() {
var xmlHttp = null;
// Opera 8.0+, Firefox, Chrome, Safari
try {
xmlHttp = new XMLHttpRequest();
} catch (e) {
// Internet Explorer Browsers
try {
xmlHttp = new ActiveXObject("Msxml2.XMLHTTP");
} catch (e) {
try {
xmlHttp = new ActiveXObject("Microsoft.XMLHTTP");
} catch (e) {
return false;
}
}
}
xmlHttp.open('POST', 'AjaxHelper;jsessionid=00000000.app30110b?NONCE_TOKEN=58EAC483AE463702B31D9CBC1B331622', true);
xmlHttp.send();
}
addOnLoadHandler(testAjax);
//
-->
</script>
<div class="donation-form-content">
<input type="hidden" name="user_donation_amt" id="user_donation_amt" value="">
<input type="hidden" name="company_min_matching_amt" id="company_min_matching_amt" value="">
<input type="hidden" name="currency_locale" id="currency_locale" value="en_US">
<input type="hidden" name="re_appealhidden" id="re_appealhidden" value="P2308EM1">
<div class="form-row">
<div class="html-caption-container">
</div>
</div>
<h2 class="section-header-container"> How would you like to donate? </h2>
<div id="level_flexible_row">
<div class="don-standard-levels form-row">
<div class="levels-label">
</div>
<div id="level_flexible_row" class="form-row form-donation-level">
<div class="form-content">
<span class="field-required"></span> <span class="aural-only">Field Is Required</span>
<span class="FormLabelText">Select Gift Amount:</span>
<div class="donation-level-general-ask">
</div>
<div id="level_flexiblegift_type_Row" class="form-row field-required">
<div class="form-content">
<fieldset>
<legend> Gift type: </legend>
<div class="designated-giving-recurring-row">
<input type="radio" name="level_flexiblegift_type" id="level_flexiblegift_type1" value="1" checked="checked" onclick="fire_obs_comp_event('level_flexiblegift_type', this);"
onkeypress="fire_obs_comp_event('level_flexiblegift_type', this);">
<label for="level_flexiblegift_type1">One-Time</label>
</div>
<div class="designated-giving-recurring-row">
<input type="radio" name="level_flexiblegift_type" id="level_flexiblegift_type2" value="2" onclick="fire_obs_comp_event('level_flexiblegift_type', this);" onkeypress="fire_obs_comp_event('level_flexiblegift_type', this);">
<label for="level_flexiblegift_type2">Monthly</label><img src="https://secure3.convio.net/prkorg/Don2018/donate-help-fight-cta.png" alt="Help fight Parkinson's disease all year long!">
</div>
</fieldset>
</div>
<input type="hidden" name="level_flexiblegift_typesubmit" id="level_flexiblegift_typesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableRadioComponent('level_flexiblegift_type', 'name');
</script><noscript> </noscript>
</div>
<div class="donation-levels">
<div class="donation-level-container monthlyN">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_flexibleexpanded" id="level_flexibleexpanded28885" value="28885" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
</div>
<label for="level_flexibleexpanded28885" onclick="">$35</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_28885expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container monthlyN">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_flexibleexpanded" id="level_flexibleexpanded28886" value="28886" checked="checked" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
</div>
<label for="level_flexibleexpanded28886" onclick="" class="active">$50</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_28886expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container monthlyN">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_flexibleexpanded" id="level_flexibleexpanded28887" value="28887" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
</div>
<label for="level_flexibleexpanded28887" onclick="">$100</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_28887expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container monthlyN">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_flexibleexpanded" id="level_flexibleexpanded28888" value="28888" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
</div>
<label for="level_flexibleexpanded28888" onclick="">$250</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_28888expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container monthlyY">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_flexibleexpanded" id="level_flexibleexpanded28890" value="28890" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
</div>
<label for="level_flexibleexpanded28890" onclick="">$10</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_28890expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container monthlyY">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_flexibleexpanded" id="level_flexibleexpanded28880" value="28880" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
</div>
<label for="level_flexibleexpanded28880" onclick="">$20</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_28880expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container monthlyY">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_flexibleexpanded" id="level_flexibleexpanded28881" value="28881" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
</div>
<label for="level_flexibleexpanded28881" onclick="">$50</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_28881expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container monthlyY">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_flexibleexpanded" id="level_flexibleexpanded28882" value="28882" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
</div>
<label for="level_flexibleexpanded28882" onclick="">$100</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_28882expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container monthly-has-four-levels one-time-has-four-levels">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_flexibleexpanded" id="level_flexibleexpanded28884" value="28884" onclick="evalMatchingGift(document.getElementById('level_flexibleexpanded28884amount').value);
updateDonorCoverAmount(document.getElementById('level_flexibleexpanded28884amount').value);">
</div>
<label for="level_flexibleexpanded28884" onclick="" style="display: none;">
<div class="donation-level-label-container"> Other </div>
</label>
<div class="donation-level-user-entered">
<label for="level_flexibleexpanded28884amount"><span class="aural-only">Enter amount</span></label>
<input type="text" name="level_flexibleexpanded28884amount" id="level_flexibleexpanded28884amount" value="" size="12" maxlength="50"
onfocus="var el = document.getElementById ('level_flexibleexpanded28884');if (el) el.click(); fire_obs_comp_event('level_flexibleexpanded28884amount', this, event);evalMatchingGift(value); "
onchange="fire_obs_comp_event('level_flexibleexpanded28884amount', this, event);evalMatchingGift(value);" onkeyup="fire_obs_comp_event('level_flexibleexpanded28884amount', this, event);evalMatchingGift(value);"
onblur="fire_obs_comp_event('level_flexibleexpanded28884amount', this);updateDonorCoverAmount(value);" placeholder="Other">
</div>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_28884expandedsubmit" value="true">
</div>
</div>
</div>
</div>
<script type="text/javascript">
Y.use("jquery-ui", function(Y) {
jQuery(function() {
// subscribe observables
jQuery('div.donation-level-element-container').find('input[type="radio"]').each(function() {
var syncAction = function(obj) {
if (obj.is(':checked')) {
obj.closest('div.donation-level-container').addClass('selected');
} else {
obj.closest('div.donation-level-container').removeClass('selected');
};
return arguments.callee;
}(jQuery(this));
jQuery(this).click(function() {
jQuery('div.donation-level-container').removeClass('selected');
syncAction(jQuery(this));
});
});
});
});
</script><noscript> </noscript>
</div>
<div class="levels-gift-aid">
</div>
<input type="hidden" name="level_flexiblesubmit" id="level_flexiblesubmit" value="true">
<script type="text/javascript">
function updateDonorCoverAmount(gift) {
if (typeof updateAmount !== "undefined") {
updateAmount(gift);
}
};
function evalMatchingGift(gift) {}
</script><noscript> </noscript>
</div>
<div id="level_flexibleduration_row" class="form-row form-selectlist">
<div class="form-content">
<label class="FormLabel" for="level_flexibleduration">Select a Gift Duration:</label>
<select name="level_flexibleduration" id="level_flexibleduration" size="1" disabled="">
<option></option>
<optgroup label="Monthly">
<option value="M:0">Ongoing(Monthly)</option>
<option value="M:12">12 months</option>
</optgroup>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('level_flexibleduration', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('level_flexibleduration_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="level_flexibledurationsubmit_skip" id="level_flexibledurationsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('level_flexibleduration', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('level_flexibleduration_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('level_flexiblegift_type.2', new ComponentEnabler('level_flexibleduration'));
function level_flexibleduration_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('level_flexibleduration', src);
}
}
var el = document.getElementById('level_flexibleduration');
if (el) {
Utils.addEvent(el, 'change', level_flexibleduration_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<script type="text/javascript">
// subscribe listeners to make an ajax call to the server to calculate the total amount
Y.use('jquery-noconflict', function() {
var fetchAmountFunc = function() {
// find all the select, textarea, input, etc... and format them into key=val pairs.
var params = jQuery('#level_flexible_row :input').serialize();
// parse the path and append the key/value pairs above to the url
var url = 'https://secure3.convio.net/prkorg/site/Donation2?idb=306946705&level_flexibleajaxfetch=true&12151.donation=form1&df_id=12151&mfc_pref=T&level_flexibletotalcalculateBtn=true';
var index = url.indexOf("?");
var path = url.substring(0, index);
var args = url.substring(index + 1, url.length);
args += '&' + params;
jQuery.ajax(path, {
data: args,
success: function(data) {
if (!data) {
data = '0.00';
}
jQuery('#level_flexible_row .donation-level-total-amount').html(data);
jQuery('#recurring_gift_terms_acceptance_message_container').trigger("recurringTermsChange");
}
});
};
jQuery('#level_flexible_row :input').blur(function() {
fetchAmountFunc();
});
jQuery('#level_flexible_row input:checkbox, #level_flexible_row input:radio').click(function() {
fetchAmountFunc();
});
jQuery('#level_flexible_row select').change(function() {
fetchAmountFunc();
});
// call it on page load
fetchAmountFunc();
});
</script><noscript> </noscript>
</div>
<div id="additional_amount_row" class="form-row form-text">
<div class="form-content">
<label for="additional_amountname">Additional Amount:</label>
<div class="form-input">
<input type="text" name="additional_amountname" id="additional_amountname" value="" maxlength="15" onchange="fire_obs_comp_event('additional_amount', this);">
</div>
</div>
<input type="hidden" name="additional_amountsubmit" id="additional_amountsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('additional_amount', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('additional_amount_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('additional_amountname')) {
document.getElementById('additional_amountname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('additional_amountname')) return document.getElementById('additional_amountname').checked;
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
</div>
<h2 class="section-header-container"> Is this gift in honor or in memory of someone? </h2>
<div id="tribute_show_honor_fields_row" class="form-row form-checkbox">
<div class="form-content">
<input type="checkbox" name="tribute_show_honor_fieldsname" id="tribute_show_honor_fieldsname" onclick="fire_obs_comp_event('tribute_show_honor_fields', this);">
<label for="tribute_show_honor_fieldsname">Yes, this is an honor or memorial gift</label>
<input type="hidden" name="tribute_show_honor_fieldssubmit" id="tribute_show_honor_fieldssubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_show_honor_fields', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_show_honor_fields_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('tribute_show_honor_fieldsname')) {
document.getElementById('tribute_show_honor_fieldsname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('tribute_show_honor_fieldsname')) {
return document.getElementById('tribute_show_honor_fieldsname').checked;
}
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_type_row" class="form-row form-selectlist" style="display: none;">
<div class="form-content">
<label class="FormLabel" for="tribute_type">Honor Gift Type:</label>
<select name="tribute_type" id="tribute_type" size="1">
<option></option>
<option value="tribute_type_value1">In Memory of</option>
<option value="tribute_type_value2">In Honor of</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('tribute_type', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_type_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="tribute_typesubmit_skip" id="tribute_typesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_type', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_type_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_type'));
function tribute_type_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('tribute_type', src);
}
}
var el = document.getElementById('tribute_type');
if (el) {
Utils.addEvent(el, 'change', tribute_type_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<div class="fakeTribute row">
<div class="col-6">
<input type="radio" id="fakeTributeYes" name="fakeTribute" value="yes">
<label for="fakeTributeYes">Yes</label>
</div>
<div class="col-6">
<input type="radio" id="fakeTributeNo" name="fakeTribute" value="no">
<label for="fakeTributeNo">No</label>
</div>
</div>
<div class="fakeTributeType row" style="display: none;">
<div class="col-sm-12 col-md-6">
<input type="radio" id="fakeTributeTypeHonor" name="fakeTributeType" value="honor">
<label for="fakeTributeTypeHonor">In Honor</label>
</div>
<div class="col-sm-12 col-md-6">
<input type="radio" id="fakeTributeTypeMemorial" name="fakeTributeType" value="memory">
<label for="fakeTributeTypeMemorial">In Memory</label>
</div>
</div>
<p class="tributeTypePrompt" style="display: none;">Make my gift in <span class="honor" style="display: none;">honor</span><span class="memory">memory</span> of:</p>
</div>
</div>
<div id="tribute_honoree_first_name_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_honoree_first_namename">First Name:*</label>
<input type="text" name="tribute_honoree_first_namename" id="tribute_honoree_first_namename" value="" maxlength="50">
<input type="hidden" name="tribute_honoree_first_namesubmit_skip" id="tribute_honoree_first_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_honoree_first_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_honoree_first_name_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_honoree_first_name'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_honoree_last_name_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_honoree_last_namename">Last Name:*</label>
<input type="text" name="tribute_honoree_last_namename" id="tribute_honoree_last_namename" value="" maxlength="50">
<input type="hidden" name="tribute_honoree_last_namesubmit_skip" id="tribute_honoree_last_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_honoree_last_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_honoree_last_name_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_honoree_last_name'));
</script><noscript> </noscript>
</div>
</div>
<h2 class="section-header-container tribute-card-type" style="display: none;"> Card Type </h2>
<div id="send_ecard_row" class="form-row form-checkbox" style="display: none;">
<div class="form-content">
<input type="checkbox" name="send_ecardname" id="send_ecardname" onclick="fire_obs_comp_event('send_ecard', this);">
<label for="send_ecardname">Send an eCard</label>
<input type="hidden" name="send_ecardsubmit" id="send_ecardsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('send_ecard', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('send_ecard_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('send_ecardname')) {
document.getElementById('send_ecardname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('send_ecardname')) {
return document.getElementById('send_ecardname').checked;
}
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
</div>
</div>
<div class="custom-field-container form-row sendPrintCard" style="display: none;">
<div class="form-content">
<div class="form-input-label-block">
<label for="send_card_dropdown">Send a Print Card</label>
</div>
<fieldset>
<input type="checkbox" name="send_card_radio" id="send_card_radio" value="true">
<label class="custom-element-checkbox-label" for="send_card_radio">Send a Print Card</label>
</fieldset>
<input type="hidden" name="send_cardsubmit" id="send_cardsubmit" value="true">
</div>
</div>
<div id="ecard_recpients_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="ecard_recpientsname">Recipient email address(es):*</label>
<textarea cols="60" rows="4" name="ecard_recpientsname" id="ecard_recpientsname"></textarea>
<input type="hidden" name="ecard_recpientssubmit" id="ecard_recpientssubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('ecard_recpients', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('ecard_recpients_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="select_grid_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<label for="select_gridname">Select an eCard:</label>
<input type="hidden" name="stationery_layout_chooser" id="stationery_layout_chooser" value="true">
<div class="layout-chooser-container clearfix">
<div class="layout-choice-thumbnail-container">
<label class="layout-choice-thumbnail-label" for="stationery_layout_id_7183">
<img src="../images/stationery/layout_thumbnail_7183.1583690029.custom.png" alt="Donation Form Honor/Tribute eCard" border="0">
</label>
<input type="radio" name="stationery_layout_id" id="stationery_layout_id_7183" value="7183" checked="checked">
</div>
<div class="layout-choice-thumbnail-container">
<label class="layout-choice-thumbnail-label" for="stationery_layout_id_7162">
<img src="../images/stationery/layout_thumbnail_7162.335686611.custom.png" alt="Donation Form Memorial eCard" border="0">
</label>
<input type="radio" name="stationery_layout_id" id="stationery_layout_id_7162" value="7162">
</div>
</div>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('select_grid', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('select_grid_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script><noscript> </noscript>
<input type="hidden" name="select_gridsubmit" id="select_gridsubmit" value="true">
</div>
</div>
<div id="tribute_ecard_subject_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<label for="tribute_ecard_subjectname">eCard Subject:</label>
<input type="text" name="tribute_ecard_subjectname" id="tribute_ecard_subjectname" value="" maxlength="50">
<input type="hidden" name="tribute_ecard_subjectsubmit" id="tribute_ecard_subjectsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_ecard_subject', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_ecard_subject_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_ecard_message_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<label for="tribute_ecard_messagename">eCard Message:</label>
<textarea cols="60" rows="4" name="tribute_ecard_messagename" id="tribute_ecard_messagename"></textarea>
<input type="hidden" name="tribute_ecard_messagesubmit" id="tribute_ecard_messagesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_ecard_message', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_ecard_message_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="preview_button_row" class="form-row" style="display: none;">
<label for="preview_buttonname"></label>
<div id="null_row" class="form-row form-button">
<div class="form-content">
<button class="step-button action-button" type="submit" name="nullbtn" id="nullbtn" value="View eCard Preview" title="Reloads page. "> View eCard Preview </button>
<input type="hidden" name="nullsubmit" id="nullsubmit" value="true">
</div>
</div>
<input type="hidden" name="preview_buttonsubmit" id="preview_buttonsubmit" value="true">
</div>
<div id="tribute_notify_recip_name_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<label for="tribute_notify_recip_namename">Recipient Name:</label>
<input type="text" name="tribute_notify_recip_namename" id="tribute_notify_recip_namename" value="" maxlength="70">
<input type="hidden" name="tribute_notify_recip_namesubmit_skip" id="tribute_notify_recip_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_name_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_name'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_street1_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<label for="tribute_notify_recip_street1name">Address:</label>
<input type="text" name="tribute_notify_recip_street1name" id="tribute_notify_recip_street1name" value="" maxlength="50">
<input type="hidden" name="tribute_notify_recip_street1submit_skip" id="tribute_notify_recip_street1submit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_street1', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_street1_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_street1'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_city_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<label for="tribute_notify_recip_cityname">City:</label>
<input type="text" name="tribute_notify_recip_cityname" id="tribute_notify_recip_cityname" value="" maxlength="50">
<input type="hidden" name="tribute_notify_recip_citysubmit_skip" id="tribute_notify_recip_citysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_city', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_city_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_city'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_state_row" class="form-row form-selectlist" style="display: none;">
<div class="form-content">
<label class="FormLabel" for="tribute_notify_recip_state">State:</label>
<select name="tribute_notify_recip_state" id="tribute_notify_recip_state" size="1" onchange="fire_obs_comp_event('tribute_notify_recip_state', this)">
<option></option>
<option value="AK">AK - Alaska</option>
<option value="AL">AL - Alabama</option>
<option value="AR">AR - Arkansas</option>
<option value="AZ">AZ - Arizona</option>
<option value="CA">CA - California</option>
<option value="CO">CO - Colorado</option>
<option value="CT">CT - Connecticut</option>
<option value="DC">DC - District of Columbia</option>
<option value="DE">DE - Delaware</option>
<option value="FL">FL - Florida</option>
<option value="GA">GA - Georgia</option>
<option value="HI">HI - Hawaii</option>
<option value="IA">IA - Iowa</option>
<option value="ID">ID - Idaho</option>
<option value="IL">IL - Illinois</option>
<option value="IN">IN - Indiana</option>
<option value="KS">KS - Kansas</option>
<option value="KY">KY - Kentucky</option>
<option value="LA">LA - Louisiana</option>
<option value="MA">MA - Massachusetts</option>
<option value="MD">MD - Maryland</option>
<option value="ME">ME - Maine</option>
<option value="MI">MI - Michigan</option>
<option value="MN">MN - Minnesota</option>
<option value="MO">MO - Missouri</option>
<option value="MS">MS - Mississippi</option>
<option value="MT">MT - Montana</option>
<option value="NC">NC - North Carolina</option>
<option value="ND">ND - North Dakota</option>
<option value="NE">NE - Nebraska</option>
<option value="NH">NH - New Hampshire</option>
<option value="NJ">NJ - New Jersey</option>
<option value="NM">NM - New Mexico</option>
<option value="NV">NV - Nevada</option>
<option value="NY">NY - New York</option>
<option value="OH">OH - Ohio</option>
<option value="OK">OK - Oklahoma</option>
<option value="OR">OR - Oregon</option>
<option value="PA">PA - Pennsylvania</option>
<option value="RI">RI - Rhode Island</option>
<option value="SC">SC - South Carolina</option>
<option value="SD">SD - South Dakota</option>
<option value="TN">TN - Tennessee</option>
<option value="TX">TX - Texas</option>
<option value="UT">UT - Utah</option>
<option value="VA">VA - Virginia</option>
<option value="VT">VT - Vermont</option>
<option value="WA">WA - Washington</option>
<option value="WI">WI - Wisconsin</option>
<option value="WV">WV - West Virginia</option>
<option value="WY">WY - Wyoming</option>
<option value="AS">AS - American Samoa</option>
<option value="FM">FM - Federated States of Micronesia</option>
<option value="GU">GU - Guam</option>
<option value="MH">MH - Marshall Islands</option>
<option value="MP">MP - Northern Mariana Islands</option>
<option value="PR">PR - Puerto Rico</option>
<option value="PW">PW - Palau</option>
<option value="VI">VI - Virgin Islands</option>
<option value="AA">AA - Armed Forces Americas</option>
<option value="AE">AE - Armed Forces</option>
<option value="AP">AP - Armed Forces Pacific</option>
<option value="AB">AB - Alberta</option>
<option value="BC">BC - British Columbia</option>
<option value="MB">MB - Manitoba</option>
<option value="NB">NB - New Brunswick</option>
<option value="NL">NL - Newfoundland and Labrador</option>
<option value="NS">NS - Nova Scotia</option>
<option value="NT">NT - Northwest Territories</option>
<option value="NU">NU - Nunavut</option>
<option value="ON">ON - Ontario</option>
<option value="PE">PE - Prince Edward Island</option>
<option value="QC">QC - Quebec</option>
<option value="SK">SK - Saskatchewan</option>
<option value="YT">YT - Yukon</option>
<option value="None">None</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('tribute_notify_recip_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_state_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="tribute_notify_recip_statesubmit_skip" id="tribute_notify_recip_statesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_state_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_state'));
function tribute_notify_recip_state_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('tribute_notify_recip_state', src);
}
}
var el = document.getElementById('tribute_notify_recip_state');
if (el) {
Utils.addEvent(el, 'change', tribute_notify_recip_state_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_zip_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<label for="tribute_notify_recip_zipname">Zip:</label>
<input type="text" name="tribute_notify_recip_zipname" id="tribute_notify_recip_zipname" value="" maxlength="50">
<input type="hidden" name="tribute_notify_recip_zipsubmit_skip" id="tribute_notify_recip_zipsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_zip', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_zip_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_zip'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_country_row" class="form-row form-selectlist" style="display: none;">
<div class="form-content">
<label class="FormLabel" for="tribute_notify_recip_country">Country:</label>
<select name="tribute_notify_recip_country" id="tribute_notify_recip_country" size="1" onchange="fire_obs_comp_event('tribute_notify_recip_country', this)">
<option></option>
<option selected="selected" value="United States">United States</option>
<option value="Afghanistan">Afghanistan</option>
<option value="Aland Islands">Aland Islands</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antarctica">Antarctica</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivarian Republic of Venezuela">Bolivarian Republic of Venezuela</option>
<option value="Bonaire, Sint Eustatios and Saba">Bonaire, Sint Eustatios and Saba</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet Island">Bouvet Island</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
<option value="Brunei Darussalam">Brunei Darussalam</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cape Verde">Cape Verde</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Cote D'Ivoire">Cote D'Ivoire</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Curacao">Curacao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</option>
<option value="Democratic People's Republic of Korea">Democratic People's Republic of Korea</option>
<option value="The Democratic Republic of the Congo">The Democratic Republic of the Congo</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Falkland Islands (Malvinas)">Falkland Islands (Malvinas)</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Federated States of Micronesia">Federated States of Micronesia</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="The Former Yugoslav Republic of Macedonia">The Former Yugoslav Republic of Macedonia</option>
<option value="France">France</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern Territories">French Southern Territories</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guernsey">Guernsey</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option>
<option value="Holy See (Vatican City State)">Holy See (Vatican City State)</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Islamic Republic of Iran">Islamic Republic of Iran</option>
<option value="Isle of Man">Isle of Man</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jersey">Jersey</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macao">Macao</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montenegro">Montenegro</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestinian Territory, Occupied">Palestinian Territory, Occupied</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Pitcairn">Pitcairn</option>
<option value="Plurinational State of Bolivia">Plurinational State of Bolivia</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Republic of Korea">Republic of Korea</option>
<option value="Republic of Moldova">Republic of Moldova</option>
<option value="Reunion">Reunion</option>
<option value="Romania">Romania</option>
<option value="Russian Federation">Russian Federation</option>
<option value="Rwanda">Rwanda</option>
<option value="Saint Barthelemy">Saint Barthelemy</option>
<option value="Saint Helena, Ascension and Tristan da Cunha">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Martin (French)">Saint Martin (French)</option>
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia">Serbia</option>
<option value="Seychelles">Seychelles</option>
<option value="S. Georgia & S. Sandwich Isls.">S. Georgia & S. Sandwich Isls.</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Sint Maarten (Dutch)">Sint Maarten (Dutch)</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="South Sudan">South Sudan</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
<option value="Swaziland">Swaziland</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syrian Arab Republic">Syrian Arab Republic</option>
<option value="Taiwan, Province of China">Taiwan, Province of China</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Thailand">Thailand</option>
<option value="Timor-Leste">Timor-Leste</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkey">Turkey</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="United Republic of Tanzania">United Republic of Tanzania</option>
<option value="Uruguay">Uruguay</option>
<option value="USA Minor Outlying Islands">USA Minor Outlying Islands</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Viet Nam">Viet Nam</option>
<option value="Virgin Islands (British)">Virgin Islands (British)</option>
<option value="Virgin Islands (USA)">Virgin Islands (USA)</option>
<option value="Wallis and Futuna">Wallis and Futuna</option>
<option value="Western Sahara">Western Sahara</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('tribute_notify_recip_country', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_country_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="tribute_notify_recip_countrysubmit_skip" id="tribute_notify_recip_countrysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_country', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_country_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_country'));
function tribute_notify_recip_country_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('tribute_notify_recip_country', src);
}
}
var el = document.getElementById('tribute_notify_recip_country');
if (el) {
Utils.addEvent(el, 'change', tribute_notify_recip_country_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div class="custom-field-container form-row " style="display: none;">
<div class="form-content">
<div class="form-input-label-block">
<label for="special_gift_instructions_input">Special Instructions:</label>
</div>
<input type="text" name="special_gift_instructions_input" id="special_gift_instructions_input" value="" maxlength="255">
<input type="hidden" name="special_gift_instructionssubmit" id="special_gift_instructionssubmit" value="true">
</div>
</div>
<h2 class="section-header-container"> Your Information: </h2>
<div id="billing_first_name_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_first_namename">First Name:*</label>
<input type="text" name="billing_first_namename" id="billing_first_namename" value="" maxlength="50">
<input type="hidden" name="billing_first_namesubmit" id="billing_first_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_first_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_first_name_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_last_name_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_last_namename">Last Name:*</label>
<input type="text" name="billing_last_namename" id="billing_last_namename" value="" maxlength="50">
<input type="hidden" name="billing_last_namesubmit" id="billing_last_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_last_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_last_name_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_street1_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_addr_street1name">Address:*</label>
<input type="text" name="billing_addr_street1name" id="billing_addr_street1name" value="" maxlength="50">
<input type="hidden" name="billing_addr_street1submit" id="billing_addr_street1submit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_street1', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_street1_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_city_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_addr_cityname">City:*</label>
<input type="text" name="billing_addr_cityname" id="billing_addr_cityname" value="" maxlength="50">
<input type="hidden" name="billing_addr_citysubmit" id="billing_addr_citysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_city', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_city_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_state_row" class="form-row form-selectlist">
<div class="form-content">
<span class="field-required"></span>
<label class="FormLabel" for="billing_addr_state">State:*</label>
<select name="billing_addr_state" id="billing_addr_state" size="1" onchange="fire_obs_comp_event('billing_addr_state', this)">
<option></option>
<option value="AK">AK - Alaska</option>
<option value="AL">AL - Alabama</option>
<option value="AR">AR - Arkansas</option>
<option value="AZ">AZ - Arizona</option>
<option value="CA">CA - California</option>
<option value="CO">CO - Colorado</option>
<option value="CT">CT - Connecticut</option>
<option value="DC">DC - District of Columbia</option>
<option value="DE">DE - Delaware</option>
<option value="FL">FL - Florida</option>
<option value="GA">GA - Georgia</option>
<option value="HI">HI - Hawaii</option>
<option value="IA">IA - Iowa</option>
<option value="ID">ID - Idaho</option>
<option value="IL">IL - Illinois</option>
<option value="IN">IN - Indiana</option>
<option value="KS">KS - Kansas</option>
<option value="KY">KY - Kentucky</option>
<option value="LA">LA - Louisiana</option>
<option value="MA">MA - Massachusetts</option>
<option value="MD">MD - Maryland</option>
<option value="ME">ME - Maine</option>
<option value="MI">MI - Michigan</option>
<option value="MN">MN - Minnesota</option>
<option value="MO">MO - Missouri</option>
<option value="MS">MS - Mississippi</option>
<option value="MT">MT - Montana</option>
<option value="NC">NC - North Carolina</option>
<option value="ND">ND - North Dakota</option>
<option value="NE">NE - Nebraska</option>
<option value="NH">NH - New Hampshire</option>
<option value="NJ">NJ - New Jersey</option>
<option value="NM">NM - New Mexico</option>
<option value="NV">NV - Nevada</option>
<option value="NY">NY - New York</option>
<option value="OH">OH - Ohio</option>
<option value="OK">OK - Oklahoma</option>
<option value="OR">OR - Oregon</option>
<option value="PA">PA - Pennsylvania</option>
<option value="RI">RI - Rhode Island</option>
<option value="SC">SC - South Carolina</option>
<option value="SD">SD - South Dakota</option>
<option value="TN">TN - Tennessee</option>
<option value="TX">TX - Texas</option>
<option value="UT">UT - Utah</option>
<option value="VA">VA - Virginia</option>
<option value="VT">VT - Vermont</option>
<option value="WA">WA - Washington</option>
<option value="WI">WI - Wisconsin</option>
<option value="WV">WV - West Virginia</option>
<option value="WY">WY - Wyoming</option>
<option value="AS">AS - American Samoa</option>
<option value="FM">FM - Federated States of Micronesia</option>
<option value="GU">GU - Guam</option>
<option value="MH">MH - Marshall Islands</option>
<option value="MP">MP - Northern Mariana Islands</option>
<option value="PR">PR - Puerto Rico</option>
<option value="PW">PW - Palau</option>
<option value="VI">VI - Virgin Islands</option>
<option value="AA">AA - Armed Forces Americas</option>
<option value="AE">AE - Armed Forces</option>
<option value="AP">AP - Armed Forces Pacific</option>
<option value="AB">AB - Alberta</option>
<option value="BC">BC - British Columbia</option>
<option value="MB">MB - Manitoba</option>
<option value="NB">NB - New Brunswick</option>
<option value="NL">NL - Newfoundland and Labrador</option>
<option value="NS">NS - Nova Scotia</option>
<option value="NT">NT - Northwest Territories</option>
<option value="NU">NU - Nunavut</option>
<option value="ON">ON - Ontario</option>
<option value="PE">PE - Prince Edward Island</option>
<option value="QC">QC - Quebec</option>
<option value="SK">SK - Saskatchewan</option>
<option value="YT">YT - Yukon</option>
<option value="None">None</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('billing_addr_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_state_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="billing_addr_statesubmit" id="billing_addr_statesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_state_row', _display);
this.disable_submit_flag(_hidden);
}
function billing_addr_state_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('billing_addr_state', src);
}
}
var el = document.getElementById('billing_addr_state');
if (el) {
Utils.addEvent(el, 'change', billing_addr_state_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_zip_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_addr_zipname">Zip:*</label>
<input type="text" name="billing_addr_zipname" id="billing_addr_zipname" value="" maxlength="50">
<input type="hidden" name="billing_addr_zipsubmit" id="billing_addr_zipsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_zip', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_zip_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_country_row" class="form-row form-selectlist">
<div class="form-content">
<span class="field-required"></span>
<label class="FormLabel" for="billing_addr_country">Country:*</label>
<select name="billing_addr_country" id="billing_addr_country" size="1" onchange="fire_obs_comp_event('billing_addr_country', this)">
<option></option>
<option selected="selected" value="United States">United States</option>
<option value="Afghanistan">Afghanistan</option>
<option value="Aland Islands">Aland Islands</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antarctica">Antarctica</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivarian Republic of Venezuela">Bolivarian Republic of Venezuela</option>
<option value="Bonaire, Sint Eustatios and Saba">Bonaire, Sint Eustatios and Saba</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet Island">Bouvet Island</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
<option value="Brunei Darussalam">Brunei Darussalam</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cape Verde">Cape Verde</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Cote D'Ivoire">Cote D'Ivoire</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Curacao">Curacao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</option>
<option value="Democratic People's Republic of Korea">Democratic People's Republic of Korea</option>
<option value="The Democratic Republic of the Congo">The Democratic Republic of the Congo</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Falkland Islands (Malvinas)">Falkland Islands (Malvinas)</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Federated States of Micronesia">Federated States of Micronesia</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="The Former Yugoslav Republic of Macedonia">The Former Yugoslav Republic of Macedonia</option>
<option value="France">France</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern Territories">French Southern Territories</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guernsey">Guernsey</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option>
<option value="Holy See (Vatican City State)">Holy See (Vatican City State)</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Islamic Republic of Iran">Islamic Republic of Iran</option>
<option value="Isle of Man">Isle of Man</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jersey">Jersey</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macao">Macao</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montenegro">Montenegro</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestinian Territory, Occupied">Palestinian Territory, Occupied</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Pitcairn">Pitcairn</option>
<option value="Plurinational State of Bolivia">Plurinational State of Bolivia</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Republic of Korea">Republic of Korea</option>
<option value="Republic of Moldova">Republic of Moldova</option>
<option value="Reunion">Reunion</option>
<option value="Romania">Romania</option>
<option value="Russian Federation">Russian Federation</option>
<option value="Rwanda">Rwanda</option>
<option value="Saint Barthelemy">Saint Barthelemy</option>
<option value="Saint Helena, Ascension and Tristan da Cunha">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Martin (French)">Saint Martin (French)</option>
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia">Serbia</option>
<option value="Seychelles">Seychelles</option>
<option value="S. Georgia & S. Sandwich Isls.">S. Georgia & S. Sandwich Isls.</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Sint Maarten (Dutch)">Sint Maarten (Dutch)</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="South Sudan">South Sudan</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
<option value="Swaziland">Swaziland</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syrian Arab Republic">Syrian Arab Republic</option>
<option value="Taiwan, Province of China">Taiwan, Province of China</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Thailand">Thailand</option>
<option value="Timor-Leste">Timor-Leste</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkey">Turkey</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="United Republic of Tanzania">United Republic of Tanzania</option>
<option value="Uruguay">Uruguay</option>
<option value="USA Minor Outlying Islands">USA Minor Outlying Islands</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Viet Nam">Viet Nam</option>
<option value="Virgin Islands (British)">Virgin Islands (British)</option>
<option value="Virgin Islands (USA)">Virgin Islands (USA)</option>
<option value="Wallis and Futuna">Wallis and Futuna</option>
<option value="Western Sahara">Western Sahara</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('billing_addr_country', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_country_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="billing_addr_countrysubmit" id="billing_addr_countrysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_country', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_country_row', _display);
this.disable_submit_flag(_hidden);
}
function billing_addr_country_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('billing_addr_country', src);
}
}
var el = document.getElementById('billing_addr_country');
if (el) {
Utils.addEvent(el, 'change', billing_addr_country_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="donor_phone_row" class="form-row form-text">
<div class="form-content">
<label for="donor_phonename">Phone:</label>
<input type="text" name="donor_phonename" id="donor_phonename" value="" maxlength="50">
<input type="hidden" name="donor_phonesubmit" id="donor_phonesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_phone', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_phone_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<p style="font-size: 0.65em !important;">By providing your mobile phone number, you agree that the Parkinson's Foundation can contact you by mobile phone call and text message.</p>
</div>
</div>
<div id="donor_email_address_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="donor_email_addressname">Email:*</label>
<input type="text" name="donor_email_addressname" id="donor_email_addressname" value="" maxlength="255">
<input type="hidden" name="donor_email_addresssubmit" id="donor_email_addresssubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_email_address', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_email_address_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div class="form-row form-checkbox" id="donor_email_opt_in_Row">
<div class="form-content">
<span class="check-box-form-label-text"></span>
<input type="checkbox" name="donor_email_opt_inname" id="donor_email_opt_inname" checked="checked" onclick="fire_obs_comp_event('donor_email_opt_in', this);">
<label for="donor_email_opt_inname"> It's ok to email me. </label>
<script type="text/javascript">
var comp = new ObservableComponent('donor_email_opt_in', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_email_opt_in_Row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('donor_email_opt_inname')) {
document.getElementById('donor_email_opt_inname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('donor_email_opt_inname')) return document.getElementById('donor_email_opt_inname').checked;
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
<input type="hidden" name="donor_email_opt_insubmit" id="donor_email_opt_insubmit" value="true">
</div>
</div>
<h2 class="section-header-container"> Payment Information: </h2>
<div class="payment-type-element-container">
<div id="payment_cc_container" class="payment-field-container">
<h3>Credit Card Information:</h3>
<div id="payment_typecc_type_row" class="form-row form-radio-array">
<div class="form-content">
<fieldset>
<legend>Credit Card Type:</legend>
<ul class="radio-array-list">
<li class="tender-row ">
<img src="../images/discovercard_sm.gif" alt="Discover" name="payment_typecc_type_Discover" id="payment_typecc_type_Discover">
</li>
<li class="tender-row ">
<img src="../images/amex_small.gif" alt="American Express" name="payment_typecc_type_American_Express" id="payment_typecc_type_American_Express">
</li>
<li class="tender-row ">
<img src="../images/mastercd_small.gif" alt="MasterCard" name="payment_typecc_type_MasterCard" id="payment_typecc_type_MasterCard">
</li>
<li class="tender-row ">
<img src="../images/visa_small.gif" alt="Visa" name="payment_typecc_type_Visa" id="payment_typecc_type_Visa">
</li>
</ul>
</fieldset>
<input type="hidden" name="payment_typecc_typesubmit" id="payment_typecc_typesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableRadioComponent('payment_typecc_type', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('payment_typecc_type_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="payment_typecc_number_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="payment_typecc_numbername">Credit Card Number:</label>
<input type="text" name="payment_typecc_numbername" id="payment_typecc_numbername" value="" maxlength="22" autocomplete="off">
<input type="hidden" name="payment_typecc_numbersubmit" id="payment_typecc_numbersubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('payment_typecc_number', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('payment_typecc_number_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('null', new ComponentDisplayer('payment_typecc_number'));
</script><noscript> </noscript>
</div>
</div>
<div id="payment_typecc_exp_date_row" class="form-row form-date">
<div class="form-content">
<span class="field-required"></span>
<label for="payment_typecc_exp_date_MONTH">
<span class="label-text">Expiration Date:</span><span class="aural-only">Select month of credit card</span>
</label>
<label for="payment_typecc_exp_date_YEAR"><span class="aural-only">Select Expiration Year</span></label>
<div class="date-input-container">
<fieldset class="cardExpGroup">
<select name="payment_typecc_exp_date_MONTH" id="payment_typecc_exp_date_MONTH" onchange="fire_obs_comp_event('payment_typecc_exp_date_MONTH', this)">
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8">08</option>
<option value="9">09</option>
<option value="10">10</option>
<option value="11" selected="selected">11</option>
<option value="12">12</option>
</select>
<select name="payment_typecc_exp_date_YEAR" id="payment_typecc_exp_date_YEAR" onchange="fire_obs_comp_event('payment_typecc_exp_date_YEAR', this)">
<option value="2022" selected="selected">2022</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
<option value="2027">2027</option>
<option value="2028">2028</option>
<option value="2029">2029</option>
<option value="2030">2030</option>
<option value="2031">2031</option>
<option value="2032">2032</option>
</select>
</fieldset>
<input type="hidden" name="payment_typecc_exp_date_DAY" id="payment_typecc_exp_date_DAY" value="1">
<script type="text/javascript">
<!--
var comp1 = new ObservableComponent('payment_typecc_exp_date_MONTH', '');
comp1.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('payment_typecc_exp_date_Row', _display);
this.disable_submit_flag(_hidden);
}
var comp2 = new ObservableComponent('payment_typecc_exp_date_YEAR', '');
comp2.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('payment_typecc_exp_date_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script><noscript> </noscript>
</div>
<input type="hidden" name="payment_typecc_exp_datesubmit" id="payment_typecc_exp_datesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('payment_typecc_exp_date', 'input');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('payment_typecc_exp_date_row', _display);
disable_submit_flag('payment_typecc_exp_datesubmit', _hidden);
}
comp.disable = function(_disabled) {
disable_element('payment_typecc_exp_date_MONTH', _disabled);
disable_element('payment_typecc_exp_date_DAY', _disabled);
disable_element('payment_typecc_exp_date_YEAR', _disabled);
disable_element('payment_typecc_exp_date_HOUR12', _disabled);
disable_element('payment_typecc_exp_date_HOUR24', _disabled); //For UK, 24 hour clock used
disable_element('payment_typecc_exp_date_MINUTE', _disabled);
disable_element('payment_typecc_exp_date_AMPM', _disabled);
}
</script><noscript> </noscript>
</div>
</div>
<div id="payment_typecc_cvv_row" class="form-row form-text cvv-input">
<div class="form-content">
<span class="field-required"></span>
<label for="payment_typecc_cvvname">
<span class="FormLabelText">CVV Number:</span>
</label>
<input type="text" name="payment_typecc_cvvname" id="payment_typecc_cvvname" value="" maxlength="4"
autocomplete="cc-csc"><a href="http://help.convio.net/site/PageServer?s_site=prkorg&pagename=user_donation_cvv" class="HelpLink" title="What is this? Opens new window.">What is this?</a>
<input type="hidden" name="payment_typecc_cvvsubmit" id="payment_typecc_cvvsubmit" value="true">
<script type="text/javascript">
//chrome is mapping cvv as card name
if (/Chrome/.test(navigator.userAgent) && /Google Inc/.test(navigator.vendor)) {
document.getElementById('payment_typecc_cvvname').autocomplete = 'cc-csc';
}
var comp = new ObservableComponent('payment_typecc_cvv', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('payment_typecc_cvv_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
</div>
<input type="hidden" name="payment_typesubmit" id="payment_typesubmit" value="true">
<script type="text/javascript">
function PaymentObserver() {
this.observe = function(_event) {
var sVal = _event.component.get();
switch (sVal) {
case 'check':
hide_element('payment_cc_container');
hide_element('payment_bank_container');
show_element('payment_check_container');
break;
case 'credit':
hide_element('payment_bank_container');
hide_element('payment_check_container');
show_element('payment_cc_container');
break;
case 'ach':
hide_element('payment_cc_container');
hide_element('payment_check_container');
show_element('payment_bank_container');
break;
case 'paypal':
case 'amazon':
case 'mobilepay':
default:
// hide all
hide_element('payment_bank_container');
hide_element('payment_cc_container');
hide_element('payment_check_container');
break;
}
}
}
// Set the observer to show/hide the relevant fields
observe_component('payment_typepay_typeradio', new PaymentObserver());
</script><noscript> </noscript>
</div>
<div class="custom-field-container form-row processingFee">
<div class="form-content">
<div class="form-input-label-block">
<label for="processing_fee_yesno_dropdown">Processing Fee YesNo</label>
</div>
<fieldset>
<input type="checkbox" name="processing_fee_yesno_radio" id="processing_fee_yesno_radio" value="true">
<label class="custom-element-checkbox-label" for="processing_fee_yesno_radio">I'd like to donate an additional $1.50 to cover the transaction fee.</label>
</fieldset>
<input type="hidden" name="processing_fee_yesnosubmit" id="processing_fee_yesnosubmit" value="true">
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
</div>
</div>
<div class="button-container clearfix">
<div class="button-sub-container">
<button class="step-button action-button finish-step" type="submit" id="pstep_finish" name="pstep_finish" value="Donate Now">DONATE $50.00</button>
</div>
</div>
<input type="hidden" name="idb" id="idb" value="306946705">
<input type="hidden" name="df_id" id="df_id" value="12151">
<input type="hidden" name="mfc_pref" id="mfc_pref" value="T">
<div class="form-row">
<div class="html-caption-container">
<p style="font-size: 0.6em !important;">*Gifts received by November 29, 2022, in response to our Matching Gift Challenge will be matched up to $10,000. Funds raised over $10,000 will not be matched but will support the critical work of the
Parkinson’s Foundation.</p>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<script id="form-placeholders" type="text/json">
[
[".donation-levels input[type=\"text\"]", "$ Other (USD)"]
]
</script>
<!-- Each entry in the placeholder list should be
a pair of strings. The first string should be a
valid CSS selector for the field to modify. The
second string should be the text to insert as a
placeholder.
For example:
[
[ '#billing_first_namename', 'e.g., "John"' ],
[ '#billing_last_namename', 'e.g., "Smith"' ],
]
-->
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<div id="geoTrust" class="col">
<script src="//smarticon.geotrust.com/si.js" type="text/javascript"></script>
</div>
</div>
</div>
<div id="captcha_row" class="form-row form-captcha">
<div class="form-content">
<input type="hidden" name="captcha_text" id="captcha_text" value="">
<input type="hidden" name="captcha_text_proxy_submit" id="captcha_text_proxy_submit" value="">
<script src="https://www.google.com/recaptcha/api.js?render=6LcVyLgZAAAAAIaCdeocZ0n27ZV5AVFs-ptKOles"></script>
<script type="text/javascript">
Y.use('jquery-noconflict', function() {
jQuery(document).ready(function() {
jQuery('#captcha_text').parents('form').find('input[type="submit"], button[type="submit"]').click(function(e) {
e.preventDefault();
e.stopPropagation();
jQuery('#captcha_text_proxy_submit').val(this.value);
jQuery('#captcha_text_proxy_submit').prop('name', this.name);
grecaptcha.ready(function() {
grecaptcha.execute('6LcVyLgZAAAAAIaCdeocZ0n27ZV5AVFs-ptKOles', {
action: 'submit'
}).then(function(token) {
jQuery('#captcha_text').val(token);
if (typeof checkDoubleClick === "function") {
if (checkDoubleClick()) {
jQuery('#captcha_text').parents('form')[0].submit();
}
} else {
jQuery('#captcha_text').parents('form')[0].submit();
}
});
});
});
});
});
</script>
<style type="text/css">
.grecaptcha-badge {
visibility: visible !important;
}
</style>
</div>
<input type="hidden" name="captchasubmit" id="captchasubmit" value="true">
</div>
</div>
<input type="hidden" name="12151.donation" id="12151.donation" value="form1">
</div>
<script type="text/javascript">
var submitted = false;
function checkDoubleClick() {
var elCheck = '';
if (elCheck == 'el') {
alert('Form submission is not enabled when previewing an individual data element.');
return false;
} else if (submitted) {
alert('You have already submitted this payment. Please wait....');
return false;
} else {
submitted = true;
return true;
}
}
</script><noscript> </noscript>
</form>Text Content
PFLogo * A * A * GIVING TUESDAY TRIPLE MATCH* Your gift will be triple matched to help the Parkinson’s Foundation invest in research toward a cure, raise awareness and improve the lives of everyone in the Parkinson’s community. Please make a generous gift today to have three times the impact! HOW WOULD YOU LIKE TO DONATE? Field Is Required Select Gift Amount: Gift type: One-Time Monthly $35 $50 $100 $250 $10 $20 $50 $100 Other Enter amount Select a Gift Duration: Ongoing(Monthly) 12 months Required Additional Amount: IS THIS GIFT IN HONOR OR IN MEMORY OF SOMEONE? Yes, this is an honor or memorial gift Honor Gift Type: In Memory of In Honor of Required Yes No In Honor In Memory Make my gift in honormemory of: First Name:* Last Name:* CARD TYPE Send an eCard Send a Print Card Send a Print Card Recipient email address(es):* Select an eCard: eCard Subject: eCard Message: View eCard Preview Recipient Name: Address: City: State: AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida GA - Georgia HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming AS - American Samoa FM - Federated States of Micronesia GU - Guam MH - Marshall Islands MP - Northern Mariana Islands PR - Puerto Rico PW - Palau VI - Virgin Islands AA - Armed Forces Americas AE - Armed Forces AP - Armed Forces Pacific AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NL - Newfoundland and Labrador NS - Nova Scotia NT - Northwest Territories NU - Nunavut ON - Ontario PE - Prince Edward Island QC - Quebec SK - Saskatchewan YT - Yukon None Required Zip: Country: United States Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivarian Republic of Venezuela Bonaire, Sint Eustatios and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Democratic People's Republic of Korea The Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Federated States of Micronesia Fiji Finland The Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iraq Ireland Islamic Republic of Iran Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Plurinational State of Bolivia Poland Portugal Puerto Rico Qatar Republic of Korea Republic of Moldova Reunion Romania Russian Federation Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles S. Georgia & S. Sandwich Isls. Sierra Leone Singapore Sint Maarten (Dutch) Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United Republic of Tanzania Uruguay USA Minor Outlying Islands Uzbekistan Vanuatu Viet Nam Virgin Islands (British) Virgin Islands (USA) Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Required Special Instructions: YOUR INFORMATION: First Name:* Last Name:* Address:* City:* State:* AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida GA - Georgia HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming AS - American Samoa FM - Federated States of Micronesia GU - Guam MH - Marshall Islands MP - Northern Mariana Islands PR - Puerto Rico PW - Palau VI - Virgin Islands AA - Armed Forces Americas AE - Armed Forces AP - Armed Forces Pacific AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NL - Newfoundland and Labrador NS - Nova Scotia NT - Northwest Territories NU - Nunavut ON - Ontario PE - Prince Edward Island QC - Quebec SK - Saskatchewan YT - Yukon None Required Zip:* Country:* United States Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivarian Republic of Venezuela Bonaire, Sint Eustatios and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Democratic People's Republic of Korea The Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Federated States of Micronesia Fiji Finland The Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iraq Ireland Islamic Republic of Iran Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Plurinational State of Bolivia Poland Portugal Puerto Rico Qatar Republic of Korea Republic of Moldova Reunion Romania Russian Federation Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles S. Georgia & S. Sandwich Isls. Sierra Leone Singapore Sint Maarten (Dutch) Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United Republic of Tanzania Uruguay USA Minor Outlying Islands Uzbekistan Vanuatu Viet Nam Virgin Islands (British) Virgin Islands (USA) Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Required Phone: By providing your mobile phone number, you agree that the Parkinson's Foundation can contact you by mobile phone call and text message. Email:* It's ok to email me. PAYMENT INFORMATION: CREDIT CARD INFORMATION: Credit Card Type: * * * * Credit Card Number: Expiration Date:Select month of credit card Select Expiration Year 01 02 03 04 05 06 07 08 09 10 11 12 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 CVV Number: What is this? Processing Fee YesNo I'd like to donate an additional $1.50 to cover the transaction fee. DONATE $50.00 *Gifts received by November 29, 2022, in response to our Matching Gift Challenge will be matched up to $10,000. Funds raised over $10,000 will not be matched but will support the critical work of the Parkinson’s Foundation. PFLogo Questions? Call our Helpline: 1-800-4PD-INFO (473-4636) © 2022 Parkinson’s Foundation Miami: 200 SE 1st Street, Suite 800, Miami, FL 33131 NY: 1359 Broadway, Suite 1509, New York, NY 10018 contact@parkinson.org | Privacy & Terms The Parkinson's Foundation is a 501(c)(3) nonprofit organization. EIN: 13-1866796