secure3.convio.net
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Submitted URL: https://secure3.convio.net/prkorg/site/R?i=l3D9DaQC22STHvmgDHef-C_qs8ZVnVUpRhjH6Rkf02J4-UMj6V8xvA
Effective URL: https://secure3.convio.net/prkorg/site/Donation2?10153.donation=form1&idb=2128097617&df_id=10153&mfc_pref=T&10153_donation=...
Submission: On June 03 via api from US — Scanned from DE
Effective URL: https://secure3.convio.net/prkorg/site/Donation2?10153.donation=form1&idb=2128097617&df_id=10153&mfc_pref=T&10153_donation=...
Submission: On June 03 via api 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();" autocomplete="off">
<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.app30109b?NONCE_TOKEN=B920C30A2AA8CF1EAE235C3B8057E478', true);
xmlHttp.send();
}
addOnLoadHandler(testAjax);
//
-->
</script>
<div class="donation-form-content">
<input type="hidden" name="user_donation_amt" id="user_donation_amt" value="" autocomplete="off">
<input type="hidden" name="company_min_matching_amt" id="company_min_matching_amt" value="" autocomplete="off">
<input type="hidden" name="currency_locale" id="currency_locale" value="en_US" autocomplete="off">
<div class="form-progress-bar">
<div class="progress-bar-step-container progress-bar-step-current">
<div class="progress-bar-step-number-container">1</div>
<div class="progress-bar-step-text-container">Gift & Payment Information</div>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<!--
not null dfid is
10153
-->
<!-- reus_cc_ach_paypal_styles -->
<style>
div.payment-field-container span.internal-payment {
border: 0;
background-color: transparent;
min-width: 65%;
float: left;
width: auto;
max-width: 100%;
margin-right: .13em
}
div.payment-field-container span.internal-payment span.payment-type-option {
max-width: 100%;
float: left;
margin-right: 0 .5em 0 0;
text-align: center
}
div.payment-field-container span.payment-type-option {
padding: 10px 20px;
border: 0;
color: #fff;
background: #eaeaea;
background-color: #eaeaea;
filter: none;
-moz-border-radius: .5rem;
-webkit-border-radius: .5rem;
border-radius: .5rem
}
div.payment-field-container .internal-payment span.payment-type-option.selected,
.mobile div.payment-field-container span.internal-payment span.payment-type-option.selected {
background: #f5a91d;
background: -moz-linear-gradient(top, #f5a91d 0%, #f5a91d 100%);
background: -webkit-linear-gradient(top, #f5a91d 0%, #f5a91d 100%);
background: -o-linear-gradient(top, #f5a91d 0%, #f5a91d 100%);
background: -ms-linear-gradient(top, #f5a91d 0%, #f5a91d 100%);
background: linear-gradient(to bottom, #f5a91d 0%, #f5a91d 100%);
filter: progid:DXImageTransform.Microsoft.gradient(startColorstr='#f5a91d', endColorstr='#f5a91d', GradientType=0);
color: #fff;
-moz-border: 0 solid #f5a91d;
-webkit-border: 0 solid #f5a91d;
border: 0 solid #f5a91d;
-moz-border-radius: 0;
-webkit-border-radius: 0;
border-radius: 0;
font-family: 'ff-mark-regular', sans-serif
}
div.payment-field-container .internal-payment span.payment-type-option,
.mobile div.payment-field-container span.internal-payment span.payment-type-option {
background-color: #00bfda;
background: -moz-linear-gradient(top, #00bfda 0%, #00bfda 100%);
background: -webkit-gradient(linear, left top, left bottom, color-stop(0%, #00bfda), color-stop(100%, #00bfda));
background: -webkit-linear-gradient(top, #00bfda 0%, #00bfda 100%);
background: -o-linear-gradient(top, #00bfda 0%, #00bfda 100%);
background: -ms-linear-gradient(top, #00bfda 0%, #00bfda 100%);
filter: progid:DXImageTransform.Microsoft.gradient(startColorstr='#00bfda', endColorstr='#00bfda', GradientType=0);
background: linear-gradient(top, #00bfda 0%, #00bfda 100%);
-moz-border: 0 solid #00bfda;
-webkit-border: 0 solid #00bfda;
border: 0 solid #00bfda;
-moz-border-radius: 0;
-webkit-border-radius: 0;
border-radius: 0;
font-family: 'ff-mark-regular', sans-serif
}
div.payment-field-container span.payment-type-option input[type="radio"]~label:not([for^="select"]) {
margin-bottom: 0;
margin-top: 0;
padding-left: 0
}
div.payment-field-container span.payment-type-option input[type="radio"]~label:not([for^="select"]):before {
-moz-border-radius: 0;
-webkit-border-radius: 0;
border-radius: 0;
box-shadow: none;
padding: 0;
-moz-border: 0 solid #00bfda;
-webkit-border: 0 solid #00bfda;
border: 0 solid #00bfda;
visibility: hidden;
width: 0;
height: 0
}
div.payment-field-container span.payment-type-option.selected a,
div.payment-field-container span.payment-type-option a {
color: #fff !important;
font-size: 1em;
padding: 0;
margin-top: 10px;
font-weight: 700;
text-transform: uppercase;
text-decoration: none;
font-family: 'ff-mark-regular', sans-serif
}
div.payment-field-container span.external-payment span.payment-type-option {
min-height: 52px;
-moz-border-radius: 0;
-webkit-border-radius: 0;
border-radius: 0
}
div.payment-field-container span.payment-type-option input[type="radio"]~label:not([for^="select"]) {
margin-bottom: 0;
margin-top: 0;
padding-left: 0
}
div.payment-field-container span.external-payment span.payment-type-option a img {
padding-top: .3em
}
div.payment-field-container .external-payment span.payment-type-option.selected {
border: 0;
color: #fff;
margin-right: 4px;
background-color: #dadada;
background: #dadada;
-moz-border-radius: 0;
-webkit-border-radius: 0;
border-radius: 0
}
span.payment-type-option label {
margin-bottom: 0 !important
}
#ProcessForm span.payment-type-option label {
margin-bottom: 0 !important
}
#ProcessForm div#responsive_payment_type\.account_type_row li {
display: flex;
align-items: center
}
#ProcessForm div#responsive_payment_type\.account_type_row li label {
margin: 0 !important;
line-height: 1
}
#ProcessForm label[for="responsive_payment_typeach_confirmname"] {
white-space: normal !important
}
#ProcessForm div#responsive_payment_type\.account_type_row input[type="radio"] {
width: 20px;
height: 20px;
margin: -2px 5px 0 0
}
div#billing_addr_state_row .form-content,
div#payment_bank_container .form-content {
width: 100%
}
@media screen and (max-width: 767px) {
div.payment-field-container span.internal-payment {
min-width: 100%;
max-width: 100%;
float: left
}
div.payment-field-container span.internal-payment span.payment-type-option {
min-width: 100%;
max-width: 100%;
float: left;
margin: 0 0 .5em
}
div.payment-field-container span.internal-payment .payment-type-option label,
div.payment-field-container span.internal-payment .payment-type-option label a,
div.payment-field-container span.external-payment .payment-type-option label,
div.payment-field-container span.external-payment .payment-type-option label a,
div.payment-field-container span.external-payment .payment-type-option label a img {
float: none;
display: block;
margin: 0 auto
}
div.payment-field-container span.internal-payment span.payment-type-option+span.payment-type-option {
margin-left: 0
}
div.payment-field-container span.internal-payment span.payment-type-option {
min-width: 100%;
max-width: 100%;
float: left;
margin: 0 0 .5em
}
.mobile div.payment-field-container span.external-payment,
div.payment-field-container span.external-payment,
div.payment-field-container span.external-payment .payment-type-option {
clear: both;
min-width: 100%;
max-width: 100%;
float: left
}
#ProcessForm div.form-row div.form-content {
margin: 0;
width: 100%
}
.mobile div.payment-field-container div.payment-type-selections {
width: 100%
}
}
</style>
<!-- reus_df_processing_fee_script -->
<style>
input#processing_fee_yesno_radio {
width: 25px;
height: 25px;
margin: 0 .5em 40px;
vertical-align: middle;
background: #e9e9e9;
color: #000;
float: left;
}
label[for="processing_fee_yesno_radio"] {
white-space: normal !important;
width: 100%;
max-width: 100%;
}
</style>
<script>
Y.use('jquery-noconflict', function() {
function getDonationVal() {
if (jQuery('input.other-radio').is(':checked') && jQuery('#processing_fee_yesno_radio').is(':checked')) {
var donVal = parseFloat(jQuery('.don-other').val().replace(/[^0-9\.]+/g, '')).toFixed(2);
jQuery('.don-other').on('change keyup', function() {
var donVal = parseFloat(jQuery('.don-other').val().replace(/[^0-9\.]+/g, '')).toFixed(2);
console.log('other');
if (jQuery('#processing_fee_yesno_radio').is(':checked')) {}
});
} else if (jQuery('input.other-radio').is(':checked') && !jQuery('#processing_fee_yesno_radio').is(':checked')) {
console.log('this fire?');
var donVal = parseFloat(jQuery('.don-other').val().replace(/[^0-9\.]+/g, '')).toFixed(2);
console.log(donVal);
} else {
var donVal = parseFloat(jQuery('.don-radio:checked').closest('.donation-level-input-container').find('.donation-level-amount-container').text().replace(/[^0-9\.]+/g, ''));
var donVal = Number(donVal).toFixed(2);
}
var donVal = Number(donVal).toFixed(2);
var feePercent = 3 / 100;
console.log(feePercent);
var addAmtVal = (donVal * feePercent).toFixed(2);
var newDonationVal = Number(Number((donVal) * feePercent) + Number(donVal)).toFixed(2);
// Format newDonationVal with a comma for values larger than $999
if (newDonationVal >= 1) {
newDonationVal = parseFloat(newDonationVal).toLocaleString('en-US', {
style: 'currency',
currency: 'USD',
minimumFractionDigits: 2,
});
}
jQuery('#totalDonation').text(addAmtVal);
//jQuery('button#pstep_finish').text('DONATE $'+newDonationVal+'');
if (jQuery('#processing_fee_yesno_radio').is(':checked')) {
if (isNaN(donVal)) {
jQuery('#additional_amountname').val('');
jQuery('#totalDonation').text('0');
} else {
jQuery('#additional_amountname').val(addAmtVal);
jQuery('#totalDonation').text(addAmtVal);
setTimeout(function() {
jQuery('button#pstep_finish').text('DONATE ' + newDonationVal + '');
jQuery('button#pstep_finish').each(function() {
jQuery(this).text(jQuery(this).text().replace('.00', ''));
});
}, 500);
}
} else {
jQuery('#additional_amountname').val('');
jQuery('#additional_amount_row').hide();
jQuery('#totalDonation').text('0');
setTimeout(function() {
donVal = parseFloat(donVal).toLocaleString('en-US', {
style: 'currency',
currency: 'USD',
minimumFractionDigits: 2,
});
jQuery('button#pstep_finish').text('DONATE ' + donVal + '');
jQuery('button#pstep_finish').each(function() {
jQuery(this).text(jQuery(this).text().replace('.00', ''));
});
}, 500);
}
console.log(donVal);
console.log('add val :' + addAmtVal);
jQuery('#totalDonation').text(addAmtVal);
}
jQuery(document).ready(function() {
//Offset Upsell
setTimeout(function() {
jQuery('.form-donation-level input[type=radio]:checked').parents().closest('.donation-level-container')[0].click();
}, 500);
jQuery('label[for="processing_fee_yesno_radio"]').html('I\'d like to donate an additional <span class="dollar-sign">$</span><span id="totalDonation">0</span> to cover the transaction fee.');
jQuery('#additional_amount_row, label[for="processing_fee_yesno_dropdown"]').hide();
jQuery('.donation-level-user-entered').parent().parent().parent().addClass('other-amt');
jQuery('div.other-amt input[type=text]').addClass('don-other');
jQuery('.donation-level-container input[type="radio"]').addClass('don-radio');
jQuery('div.other-amt input[type=radio]').addClass('other-radio');
jQuery('.donation-level-container:not(".other-amt")').click(function() {
getDonationVal();
});
jQuery('.donation-level-user-entered input.don-other').keyup(getDonationVal);
jQuery('#processing_fee_yesno_radio').change(getDonationVal);
jQuery('.donation-level-container.user-entered.other-amt.selected input[type="text"]').click(function() {
jQuery('#totalDonation').text('0');
});
});
});
</script>
</div>
</div>
<h2 class="section-header-container"> Select Gift Amount: </h2>
<div class="custom-field-container form-row custom-checkbox-monthly">
<div class="form-content">
<div class="form-input-label-block">
<label for="monthly_checkbox_flexiblesus_dropdown">Make this a Monthly Gift</label>
</div>
<fieldset>
<input type="checkbox" name="monthly_checkbox_flexiblesus_radio" id="monthly_checkbox_flexiblesus_radio" value="true" autocomplete="off">
<label class="custom-element-checkbox-label" for="monthly_checkbox_flexiblesus_radio"></label>
</fieldset>
<input type="hidden" name="monthly_checkbox_flexiblesussubmit" id="monthly_checkbox_flexiblesussubmit" value="true" autocomplete="off">
</div>
</div>
<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 class="donation-levels">
<div class="donation-level-container one-time">
<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_flexibleexpanded22400" value="22400" onclick="evalMatchingGift('$35.00');
updateDonorCoverAmount('$35.00');" class="don-radio" autocomplete="off">
</div>
<label for="level_flexibleexpanded22400" onclick="">
<div class="donation-level-amount-container"> $35.00 </div>
<div class="donation-level-label-container"> $35 </div>
</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_22400expandedsubmit" value="true" autocomplete="off">
</div>
</div>
<div class="donation-level-container one-time">
<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_flexibleexpanded22402" value="22402" onclick="evalMatchingGift('$75.00');
updateDonorCoverAmount('$75.00');" class="don-radio" autocomplete="off">
</div>
<label for="level_flexibleexpanded22402" onclick="">
<div class="donation-level-amount-container"> $75.00 </div>
<div class="donation-level-label-container"> $75 </div>
</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_22402expandedsubmit" value="true" autocomplete="off">
</div>
</div>
<div class="donation-level-container one-time selected">
<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_flexibleexpanded22404" value="22404" checked="checked" onclick="evalMatchingGift('$150.00');
updateDonorCoverAmount('$150.00');" class="don-radio" autocomplete="off">
</div>
<label for="level_flexibleexpanded22404" onclick="">
<div class="donation-level-amount-container"> $150.00 </div>
<div class="donation-level-label-container"> $150 </div>
</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_22404expandedsubmit" value="true" autocomplete="off">
</div>
</div>
<div class="donation-level-container one-time">
<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_flexibleexpanded22406" value="22406" onclick="evalMatchingGift('$500.00');
updateDonorCoverAmount('$500.00');" class="don-radio" autocomplete="off">
</div>
<label for="level_flexibleexpanded22406" onclick="">
<div class="donation-level-amount-container"> $500.00 </div>
<div class="donation-level-label-container"> $500 </div>
</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_22406expandedsubmit" value="true" autocomplete="off">
</div>
</div>
<div class="donation-level-container one-time">
<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_flexibleexpanded22408" value="22408" onclick="evalMatchingGift('$1,000.00');
updateDonorCoverAmount('$1,000.00');" class="don-radio" autocomplete="off">
</div>
<label for="level_flexibleexpanded22408" onclick="">
<div class="donation-level-amount-container"> $1,000.00 </div>
<div class="donation-level-label-container"> $1,000 </div>
</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_22408expandedsubmit" value="true" autocomplete="off">
</div>
</div>
<div class="donation-level-container monthly hidden">
<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_flexibleexpanded22412" value="22412" onclick="evalMatchingGift('$15.00');
updateDonorCoverAmount('$15.00');" class="don-radio" autocomplete="off">
</div>
<label for="level_flexibleexpanded22412" onclick="">
<div class="donation-level-amount-container"> $15.00 </div>
<div class="donation-level-label-container"> $15 </div>
</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_22412expandedsubmit" value="true" autocomplete="off">
</div>
</div>
<div class="donation-level-container monthly hidden">
<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_flexibleexpanded22396" value="22396" onclick="evalMatchingGift('$35.00');
updateDonorCoverAmount('$35.00');" class="don-radio" autocomplete="off">
</div>
<label for="level_flexibleexpanded22396" onclick="">
<div class="donation-level-amount-container"> $35.00 </div>
<div class="donation-level-label-container"> $35 </div>
</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_22396expandedsubmit" value="true" autocomplete="off">
</div>
</div>
<div class="donation-level-container monthly hidden">
<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_flexibleexpanded22397" value="22397" onclick="evalMatchingGift('$50.00');
updateDonorCoverAmount('$50.00');" class="don-radio" autocomplete="off">
</div>
<label for="level_flexibleexpanded22397" onclick="">
<div class="donation-level-amount-container"> $50.00 </div>
<div class="donation-level-label-container"> $50 </div>
</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_22397expandedsubmit" value="true" autocomplete="off">
</div>
</div>
<div class="donation-level-container monthly hidden">
<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_flexibleexpanded22398" value="22398" onclick="evalMatchingGift('$75.00');
updateDonorCoverAmount('$75.00');" class="don-radio" autocomplete="off">
</div>
<label for="level_flexibleexpanded22398" onclick="">
<div class="donation-level-amount-container"> $75.00 </div>
<div class="donation-level-label-container"> $75 </div>
</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_22398expandedsubmit" value="true" autocomplete="off">
</div>
</div>
<div class="donation-level-container monthly hidden">
<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_flexibleexpanded22399" value="22399" onclick="evalMatchingGift('$100.00');
updateDonorCoverAmount('$100.00');" class="don-radio" autocomplete="off">
</div>
<label for="level_flexibleexpanded22399" onclick="">
<div class="donation-level-amount-container"> $100.00 </div>
<div class="donation-level-label-container"> $100 </div>
</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_22399expandedsubmit" value="true" autocomplete="off">
</div>
</div>
<div class="donation-level-container user-entered other-amt">
<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_flexibleexpanded22407" value="22407" onclick="evalMatchingGift(document.getElementById('level_flexibleexpanded22407amount').value);
updateDonorCoverAmount(document.getElementById('level_flexibleexpanded22407amount').value);" class="don-radio other-radio" autocomplete="off">
</div>
<div class="donation-level-user-entered">
<label for="level_flexibleexpanded22407amount"><span class="aural-only">Enter amount</span></label>
<input type="text" name="level_flexibleexpanded22407amount" id="level_flexibleexpanded22407amount" value="" size="12" maxlength="50"
onfocus="var el = document.getElementById ('level_flexibleexpanded22407');if (el) el.click(); fire_obs_comp_event('level_flexibleexpanded22407amount', this, event);evalMatchingGift(value); "
onchange="fire_obs_comp_event('level_flexibleexpanded22407amount', this, event);evalMatchingGift(value);" onkeyup="fire_obs_comp_event('level_flexibleexpanded22407amount', this, event);evalMatchingGift(value);"
onblur="fire_obs_comp_event('level_flexibleexpanded22407amount', this);updateDonorCoverAmount(value);" placeholder="Custom Gift Amount" class="don-other" autocomplete="off">
</div>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_22407expandedsubmit" value="true" autocomplete="off">
</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" autocomplete="off">
<script type="text/javascript">
function updateDonorCoverAmount(gift) {
if (typeof updateAmount !== "undefined") {
updateAmount(gift);
}
};
function evalMatchingGift(gift) {}
</script><noscript> </noscript>
</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);" autocomplete="off">
<label for="level_flexiblegift_type1">One-time gift</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);"
autocomplete="off">
<label for="level_flexiblegift_type2">Sustaining gift</label>
</div>
</fieldset>
</div>
<input type="hidden" name="level_flexiblegift_typesubmit" id="level_flexiblegift_typesubmit" value="true" autocomplete="off">
<script type="text/javascript">
var comp = new ObservableRadioComponent('level_flexiblegift_type', 'name');
</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="" autocomplete="off">
<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" autocomplete="off">
<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>
<div id="level_flexibletotal_row" class="level-row don-level-total-row clearfix">
<span class="donation-level-total-label">Total Gift:</span>
<span class="donation-level-total-amount">$150.00</span>
</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?10153.donation=form1&idb=2128097617&level_flexibleajaxfetch=true&df_id=10153&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[type=text]').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" style="display: none;">
<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);" autocomplete="off">
</div>
</div>
<input type="hidden" name="additional_amountsubmit" id="additional_amountsubmit" value="true" autocomplete="off">
<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>
<div class="form-row">
<div class="html-caption-container">
<div class="impact-slider">
<div id="onetimeGiftMessages" class="apiForms giftMessage sectionWrap">
<div class="impact-slide amt35">
<p><img src="../images/content/pagebuilder/2020_donation_level_35.jpg" alt="Educational Materials"></p>
<p>Your kind gift of $35 provides six people with free educational materials about Parkinson's.</p>
</div>
<div class="impact-slide amt75">
<p><img src="../images/content/pagebuilder/2024_donation_level_75.jpg" alt="Hospital Safety Guide"></p>
<p>Your kind gift of $75 can provide Hospital Safety Guides to people with Parkinson’s.</p>
</div>
<div class="impact-slide amt150 active">
<p><img src="../images/content/pagebuilder/2017_donation_level_150.jpg" alt="An encouraging coach in an exercise class"></p>
<p>Your generous gift of $150 provides two exercise classes for 30 people with Parkinson's.</p>
</div>
<div class="impact-slide amt500"><img src="../images/content/pagebuilder/2017_donation_level_500.jpg" alt="Operators on the phone">
<p>When you give $500, you can help our free Helpline answer 20 calls.</p>
</div>
<div class="impact-slide amt1000"><img src="../images/content/pagebuilder/2017_donation_level_1000.jpg" alt="Scientist in the lab">
<p>Your generous gift of $1,000 helps provide grants and funding to researchers.</p>
</div>
</div>
<div id="monthlyGiftMessages" class="apiForms giftMessage sectionWrap">
<div class="impact-slide amt15">
<p><img src="../images/content/pagebuilder/2017_donation_level_15.jpg" alt="Educational Materials"></p>
<p>Your kind gift of $15 provides a free Caring and Coping Workbook.</p>
</div>
<div class="impact-slide amt35"><img src="../images/content/pagebuilder/2017_donation_level_35.jpg" alt="Educational materials">
<p>Your kind gift of $35 provides six people with free educational materials about Parkinson’s.</p>
</div>
<div class="impact-slide amt50">
<p><img src="../images/content/pagebuilder/2017_donation_level_50.jpg" alt="Aware Kit Photo"></p>
<p>Your kind gift of $50 can provide hundreds of listeners access to our popular Expert Briefings webinars.</p>
</div>
<div class="impact-slide amt75"><img src="../images/content/pagebuilder/2017_donation_level_75.jpg" alt="Parkinson's Foundation bag">
<p>Your kind gift of $75 can provide 4 free life-saving Aware in Care kits.</p>
</div>
<div class="impact-slide amt100"><img src="../images/content/pagebuilder/2017_donation_level_100.jpg" alt="Caregiving workshop image">
<p>Your kind gift of $100 allows a care partner to attend a caregiving workshop.</p>
</div>
</div>
</div>
</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" autocomplete="off">
<input type="hidden" name="billing_first_namesubmit" id="billing_first_namesubmit" value="true" autocomplete="off">
<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" autocomplete="off">
<input type="hidden" name="billing_last_namesubmit" id="billing_last_namesubmit" value="true" autocomplete="off">
<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="donor_email_address_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="donor_email_addressname">Email Address:</label>
<input type="text" name="donor_email_addressname" id="donor_email_addressname" value="" maxlength="255" autocomplete="off">
<input type="hidden" name="donor_email_addresssubmit" id="donor_email_addresssubmit" value="true" autocomplete="off">
<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 id="donor_phone_row" class="form-row form-text">
<div class="form-content">
<label for="donor_phonename">Mobile Phone:</label>
<input type="text" name="donor_phonename" id="donor_phonename" value="" maxlength="50" autocomplete="off">
<input type="hidden" name="donor_phonesubmit" id="donor_phonesubmit" value="true" autocomplete="off">
<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 form-checkbox" id="donor_email_opt_in_Row">
<div class="form-content">
<span class="check-box-form-label-text"></span>
<input type="hidden" name="donor_email_opt_inname" id="donor_email_opt_inname" value="implicit" autocomplete="off">
<span class="auto-opt-in-warning-message">
<p><span style="font-size: 16px; font-family: MarkOT,arial,sans-serif;"><em>You’ll receive email updates from us. You can unsubscribe at any time.<br></em><em>By providing your mobile phone number, you agree that we can contact you
regarding important updates for the Parkinson’s Foundation Community.</em></span></p>
</span>
<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" autocomplete="off">
</div>
</div>
<h2 class="section-header-container"> Payment Details: </h2>
<div id="address_fields">
<div id="billing_addr_country_row" class="form-row form-selectlist dnl-full-width">
<div class="form-content dnl-full-width">
<span class="field-required"></span>
<label class="FormLabel" for="billing_addr_country">Billing Country:</label>
<select name="billing_addr_country" id="billing_addr_country" size="1" onchange="fire_obs_comp_event('billing_addr_country', this)" autocomplete="off">
<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">Taiwan</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" autocomplete="off">
<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="billing_addr_street1_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_addr_street1name">Billing Address:</label>
<input type="text" name="billing_addr_street1name" id="billing_addr_street1name" value="" maxlength="50" autocomplete="off">
<ul tabindex="-1" class="us-autocomplete-pro-menu" style="display:none;"></ul>
<input type="hidden" name="billing_addr_street1submit" id="billing_addr_street1submit" value="true" autocomplete="off">
<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_street2_row" class="form-row form-text">
<div class="form-content">
<label for="billing_addr_street2name">Address Continued:</label>
<input type="text" name="billing_addr_street2name" id="billing_addr_street2name" value="" maxlength="50" autocomplete="off">
<input type="hidden" name="billing_addr_street2submit" id="billing_addr_street2submit" value="true" autocomplete="off">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_street2', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_street2_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" autocomplete="off">
<input type="hidden" name="billing_addr_citysubmit" id="billing_addr_citysubmit" value="true" autocomplete="off">
<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/Province:</label>
<select name="billing_addr_state" id="billing_addr_state" size="1" onchange="fire_obs_comp_event('billing_addr_state', this)" autocomplete="off">
<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" autocomplete="off">
<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 Code:</label>
<input type="text" name="billing_addr_zipname" id="billing_addr_zipname" value="" maxlength="50" autocomplete="off">
<input type="hidden" name="billing_addr_zipsubmit" id="billing_addr_zipsubmit" value="true" autocomplete="off">
<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>
<div class="payment-type-element-container">
<div class="payment-type-selection-container payment-field-container">
<h3>Payment Method:</h3>
<div id="responsive_payment_typepay_typeradio_row" class="form-row">
<div class="form-content">
<div class="payment-type-selections" id="responsive_payment_typepay_typeradio_payment_types">
<span class="internal-payment"><span class="payment-type-option selected"><input type="radio" name="responsive_payment_typepay_typeradio" id="responsive_payment_typepay_typeradiocredit" value="credit" checked="checked"
onclick="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" onkeypress="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" autocomplete="off"><label
for="responsive_payment_typepay_typeradiocredit"><a href="javascript:void(0);" class="payment-type-label">Credit Card</a></label>
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_typepay_typeradio', 'name');
</script><noscript> </noscript>
</span><span class="payment-type-option"><input type="radio" name="responsive_payment_typepay_typeradio" id="responsive_payment_typepay_typeradioach" value="ach"
onclick="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" onkeypress="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" autocomplete="off"><label
for="responsive_payment_typepay_typeradioach"><a href="javascript:void(0);" class="payment-type-label">Bank Account</a></label>
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_typepay_typeradio', 'name');
</script><noscript> </noscript>
</span></span>
<span class="external-payment"><span class="payment-type-option"><input type="radio" name="responsive_payment_typepay_typeradio" id="responsive_payment_typepay_typeradiopaypal" value="paypal"
onclick="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" onkeypress="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" autocomplete="off"><label
for="responsive_payment_typepay_typeradiopaypal"><a href="javascript:void(0);" class="payment-type-label"><img src="../images/payment/paypal-logo.png" alt="Pay with Paypal"></a></label>
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_typepay_typeradio', 'name');
</script><noscript> </noscript>
</span></span>
</div>
<input type="hidden" name="responsive_payment_typepay_typeradiosubmit" id="responsive_payment_typepay_typeradiosubmit" value="true" autocomplete="off">
<script type="text/javascript">
Y.use("jquery-ui", function(Y) {
jQuery(function() {
// subscribe observable for payment type options
jQuery('.payment-type-option').each(function() {
var syncAction = function(obj) {
if (obj.hasClass('selected')) {
var radioGroupName = obj.find('input').attr('name');
obj.find('input').prop('checked', true);
fire_obs_comp_event(radioGroupName, obj.find('input').get());
}
return arguments.callee;
}(jQuery(this));
jQuery(this).click(function() {
jQuery('.payment-type-option').removeClass('selected');
jQuery(this).addClass('selected');
syncAction(jQuery(this));
var selectedValue = jQuery(this).find('input').val();
if (selectedValue == 'paypal' || selectedValue == 'amazon') {
// open up a boxinator dialog
jQuery(document).trigger('redirect-external');
jQuery('#btn_next').click();
}
});
});
});
});
var comp = new ObservableRadioComponent('responsive_payment_typepay_typeradio', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typepay_typeradio_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
</div>
<div id="payment_cc_container" class="payment-field-container">
<h3>Credit Card Information:</h3>
<div id="responsive_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="responsive_payment_typecc_type_Discover" id="responsive_payment_typecc_type_Discover">
</li>
<li class="tender-row ">
<img src="../images/amex_small.gif" alt="American Express" name="responsive_payment_typecc_type_American_Express" id="responsive_payment_typecc_type_American_Express">
</li>
<li class="tender-row ">
<img src="../images/mastercd_small.gif" alt="MasterCard" name="responsive_payment_typecc_type_MasterCard" id="responsive_payment_typecc_type_MasterCard">
</li>
<li class="tender-row ">
<img src="../images/visa_small.gif" alt="Visa" name="responsive_payment_typecc_type_Visa" id="responsive_payment_typecc_type_Visa">
</li>
</ul>
</fieldset>
<input type="hidden" name="responsive_payment_typecc_typesubmit" id="responsive_payment_typecc_typesubmit" value="true" autocomplete="off">
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_typecc_type', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_type_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typecc_number_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typecc_numbername">Credit Card Number:</label>
<input type="text" name="responsive_payment_typecc_numbername" id="responsive_payment_typecc_numbername" value="" maxlength="22" autocomplete="off">
<input type="hidden" name="responsive_payment_typecc_numbersubmit" id="responsive_payment_typecc_numbersubmit" value="true" autocomplete="off">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typecc_number', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_number_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('null', new ComponentDisplayer('responsive_payment_typecc_number'));
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typecc_exp_date_row" class="form-row form-date">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_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="responsive_payment_typecc_exp_date_YEAR"><span class="aural-only">Select Expiration Year</span></label>
<div class="date-input-container">
<fieldset class="cardExpGroup">
<select name="responsive_payment_typecc_exp_date_MONTH" id="responsive_payment_typecc_exp_date_MONTH" onchange="fire_obs_comp_event('responsive_payment_typecc_exp_date_MONTH', this)" autocomplete="off">
<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" selected="selected">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">11</option>
<option value="12">12</option>
</select>
<select name="responsive_payment_typecc_exp_date_YEAR" id="responsive_payment_typecc_exp_date_YEAR" onchange="fire_obs_comp_event('responsive_payment_typecc_exp_date_YEAR', this)" autocomplete="off">
<option value="2024" selected="selected">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>
<option value="2033">2033</option>
<option value="2034">2034</option>
</select>
</fieldset>
<input type="hidden" name="responsive_payment_typecc_exp_date_DAY" id="responsive_payment_typecc_exp_date_DAY" value="1" autocomplete="off">
<script type="text/javascript">
<!--
var comp1 = new ObservableComponent('responsive_payment_typecc_exp_date_MONTH', '');
comp1.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_exp_date_Row', _display);
this.disable_submit_flag(_hidden);
}
var comp2 = new ObservableComponent('responsive_payment_typecc_exp_date_YEAR', '');
comp2.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_exp_date_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script><noscript> </noscript>
</div>
<input type="hidden" name="responsive_payment_typecc_exp_datesubmit" id="responsive_payment_typecc_exp_datesubmit" value="true" autocomplete="off">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typecc_exp_date', 'input');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_exp_date_row', _display);
disable_submit_flag('responsive_payment_typecc_exp_datesubmit', _hidden);
}
comp.disable = function(_disabled) {
disable_element('responsive_payment_typecc_exp_date_MONTH', _disabled);
disable_element('responsive_payment_typecc_exp_date_DAY', _disabled);
disable_element('responsive_payment_typecc_exp_date_YEAR', _disabled);
disable_element('responsive_payment_typecc_exp_date_HOUR12', _disabled);
disable_element('responsive_payment_typecc_exp_date_HOUR24', _disabled); //For UK, 24 hour clock used
disable_element('responsive_payment_typecc_exp_date_MINUTE', _disabled);
disable_element('responsive_payment_typecc_exp_date_AMPM', _disabled);
}
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typecc_cvv_row" class="form-row form-text cvv-input">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typecc_cvvname">
<span class="FormLabelText">CVV Number:</span>
</label>
<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="text" name="responsive_payment_typecc_cvvname" id="responsive_payment_typecc_cvvname" value="" maxlength="4" autocomplete="off">
<input type="hidden" name="responsive_payment_typecc_cvvsubmit" id="responsive_payment_typecc_cvvsubmit" value="true" autocomplete="off">
<script type="text/javascript">
//chrome is mapping cvv as card name
if (/CriOS/.test(navigator.userAgent) || (/Chrome/.test(navigator.userAgent) && /Google Inc/.test(navigator.vendor))) {
document.getElementById('responsive_payment_typecc_cvvname').autocomplete = 'cc-csc';
}
var comp = new ObservableComponent('responsive_payment_typecc_cvv', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_cvv_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
</div>
<div id="payment_bank_container" class="payment-field-container" style="display: none;">
<h3>Bank Account Withdrawl: </h3>
<div id="responsive_payment_typerouting_number_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typerouting_numbername">Bank Routing Number:</label>
<a href="http://help.convio.net/site/PageServer?s_site=prkorg&pagename=User_Donation_ACH" class="HelpLink" title="What is this? Opens new window.">What is this?</a>
<input type="text" name="responsive_payment_typerouting_numbername" id="responsive_payment_typerouting_numbername" value="" size="20" maxlength="20" onchange="fire_obs_comp_event('responsive_payment_typerouting_number', this);"
autocomplete="off">
<input type="hidden" name="responsive_payment_typerouting_numbersubmit" id="responsive_payment_typerouting_numbersubmit" value="true" autocomplete="off">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typerouting_number', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typerouting_number_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typebank_account_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typebank_accountname">Bank Account Number:</label>
<input type="text" name="responsive_payment_typebank_accountname" id="responsive_payment_typebank_accountname" value="" maxlength="20" autocomplete="off">
<input type="hidden" name="responsive_payment_typebank_accountsubmit" id="responsive_payment_typebank_accountsubmit" value="true" autocomplete="off">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typebank_account', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typebank_account_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('null', new ComponentDisplayer('responsive_payment_typebank_account'));
</script><noscript> </noscript>
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<div id="responsive_payment_typeverify_bank_account_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typeverify_bank_accountname">Verify Bank Account Number:</label>
<input type="text" name="responsive_payment_typeverify_bank_accountname" id="responsive_payment_typeverify_bank_accountname" value="" maxlength="20" autocomplete="off">
<input type="hidden" name="responsive_payment_typeverify_bank_accountsubmit" id="responsive_payment_typeverify_bank_accountsubmit" value="true" autocomplete="off">
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var comp = new ObservableComponent('responsive_payment_typeverify_bank_account', 'name');
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</div>
<div id="responsive_payment_type.account_type_row" class="form-row form-radio-array">
<div class="form-content">
<fieldset>
<legend><span class="field-required"></span> Account Type:</legend>
<ul class="radio-array-list">
<li>
<input type="radio" name="responsive_payment_type.account_type" id="responsive_payment_type.account_type_responsive_payment_typeaccount_type_checking" value="CHECKING"
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<span class="radio-label">
<label for="responsive_payment_type.account_type_responsive_payment_typeaccount_type_checking">Checking</label>
</span>
</li>
<li>
<input type="radio" name="responsive_payment_type.account_type" id="responsive_payment_type.account_type_responsive_payment_typeaccount_type_savings" value="SAVINGS"
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<span class="radio-label">
<label for="responsive_payment_type.account_type_responsive_payment_typeaccount_type_savings">Savings</label>
</span>
</li>
</ul>
</fieldset>
<input type="hidden" name="responsive_payment_type.account_typesubmit" id="responsive_payment_type.account_typesubmit" value="true" autocomplete="off">
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_type.account_type', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_type.account_type_row', _display);
this.disable_submit_flag(_hidden);
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</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typeach_confirm_row" class="form-row form-checkbox">
<div class="form-content">
<span class="field-required"></span>
<input type="checkbox" name="responsive_payment_typeach_confirmname" id="responsive_payment_typeach_confirmname" onclick="fire_obs_comp_event('responsive_payment_typeach_confirm', this);" autocomplete="off">
<label for="responsive_payment_typeach_confirmname">By checking this option, I agree to use my bank account as a payment method and authorize this organization to debit my bank account to fulfill my donation commitment.</label>
<input type="hidden" name="responsive_payment_typeach_confirmsubmit" id="responsive_payment_typeach_confirmsubmit" value="true" autocomplete="off">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typeach_confirm', 'name');
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this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('responsive_payment_typeach_confirmname')) {
document.getElementById('responsive_payment_typeach_confirmname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('responsive_payment_typeach_confirmname')) {
return document.getElementById('responsive_payment_typeach_confirmname').checked;
}
}
comp.clear = function() {
this.set(false);
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observe_component('null', new ComponentEnabler('responsive_payment_typeach_confirm'));
</script><noscript> </noscript>
</div>
</div>
</div>
<div id="payment_check_container" class="payment-field-container" style="display: none;">
<h3>Check Information</h3>
</div>
<input type="hidden" name="responsive_payment_typesubmit" id="responsive_payment_typesubmit" value="true" autocomplete="off">
<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('responsive_payment_typepay_typeradio', new PaymentObserver());
</script><noscript> </noscript>
</div>
<div class="custom-field-container form-row ">
<div class="form-content">
<div class="form-input-label-block">
<label for="processing_fee_yesno_dropdown" style="display: none;">Processing Fee YesNo</label>
</div>
<fieldset>
<input type="checkbox" name="processing_fee_yesno_radio" id="processing_fee_yesno_radio" value="true" autocomplete="off">
<label class="custom-element-checkbox-label" for="processing_fee_yesno_radio">I'd like to donate an additional <span class="dollar-sign">$</span><span id="totalDonation">4.50</span> to cover the transaction fee.</label>
</fieldset>
<input type="hidden" name="processing_fee_yesnosubmit" id="processing_fee_yesnosubmit" value="true" autocomplete="off">
</div>
</div>
<div class="button-container clearfix">
<div class="button-sub-container">
<button class="step-button action-button finish-step" type="button" id="pstep_finish" name="pstep_finish" value="DONATE">DONATE $150</button><button type="submit" style="display:none" id="hiddenSubmit" name="pstep_finish">submit</button>
</div>
</div>
<input type="hidden" name="idb" id="idb" value="2128097617" autocomplete="off">
<input type="hidden" name="df_id" id="df_id" value="10153" autocomplete="off">
<input type="hidden" name="mfc_pref" id="mfc_pref" value="T" autocomplete="off">
<div class="form-row">
<div class="html-caption-container">
<p class="sendChk">If you would like to make a donation by mail, please
<a href="https://www.parkinson.org/sites/default/files/documents/Parkinsons-Foundation-Donation-Form.pdf" target="_blank" style="font-weight: bold;">complete this form</a> and send to:</p>
<p class="sendChk"> Parkinson's Foundation<br> 200 SE 1st Street<br> Suite 800<br> Miami, FL 33131 </p>
</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="" autocomplete="off">
<input type="hidden" name="captcha_text_proxy_submit" id="captcha_text_proxy_submit" value="" autocomplete="off">
<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() {
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</script>
<style type="text/css">
.grecaptcha-badge {
visibility: visible !important;
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</style>
</div>
<input type="hidden" name="captchasubmit" id="captchasubmit" value="true" autocomplete="off">
</div>
</div>
<input type="hidden" name="10153.donation" id="10153.donation" value="form1" autocomplete="off">
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<script type="text/javascript">
var submitted = false;
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var elCheck = '';
if (elCheck == 'el') {
alert('Form submission is not enabled when previewing an individual data element.');
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</script><noscript> </noscript>
</form>Text Content
<iframe src="//www.googletagmanager.com/ns.html?id=GTM-KKWGQL" height="0" width="0" style="display:none;visibility:hidden"></iframe> Call Our HELPLINE: 1-800-4PD-INFO (473-4636) Log In * A * A * MAKE A DONATION * General Gift * Tribute Gift * Find a Fundraiser 1 Gift & Payment Information SELECT GIFT AMOUNT: Make this a Monthly Gift Field Is Required Select Gift Amount: $35.00 $35 $75.00 $75 $150.00 $150 $500.00 $500 $1,000.00 $1,000 $15.00 $15 $35.00 $35 $50.00 $50 $75.00 $75 $100.00 $100 Enter amount Gift type: One-time gift Sustaining gift Select a Gift Duration: Ongoing(Monthly) 12 months Required Total Gift: $150.00 Additional Amount: Your kind gift of $35 provides six people with free educational materials about Parkinson's. Your kind gift of $75 can provide Hospital Safety Guides to people with Parkinson’s. Your generous gift of $150 provides two exercise classes for 30 people with Parkinson's. When you give $500, you can help our free Helpline answer 20 calls. Your generous gift of $1,000 helps provide grants and funding to researchers. Your kind gift of $15 provides a free Caring and Coping Workbook. Your kind gift of $35 provides six people with free educational materials about Parkinson’s. Your kind gift of $50 can provide hundreds of listeners access to our popular Expert Briefings webinars. Your kind gift of $75 can provide 4 free life-saving Aware in Care kits. Your kind gift of $100 allows a care partner to attend a caregiving workshop. YOUR INFORMATION: First Name: Last Name: Email Address: Mobile Phone: You’ll receive email updates from us. You can unsubscribe at any time. By providing your mobile phone number, you agree that we can contact you regarding important updates for the Parkinson’s Foundation Community. PAYMENT DETAILS: Billing 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 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 Billing Address: Address Continued: City: State/Province: 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 Code: PAYMENT METHOD: Credit Card Bank Account 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 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 CVV Number: What is this? BANK ACCOUNT WITHDRAWL: Bank Routing Number: What is this? Bank Account Number: Verify Bank Account Number: Account Type: * Checking * Savings By checking this option, I agree to use my bank account as a payment method and authorize this organization to debit my bank account to fulfill my donation commitment. CHECK INFORMATION Processing Fee YesNo I'd like to donate an additional $4.50 to cover the transaction fee. DONATE $150submit If you would like to make a donation by mail, please complete this form and send to: Parkinson's Foundation 200 SE 1st Street Suite 800 Miami, FL 33131 FL: 200 SE 1st Street, Ste 800, Miami, FL 33131, USA NY: 1359 Broadway, Ste 1509, New York, NY 10018, USA Call our Helpline: 1-800-4PD-INFO (473-4636) Connect with us * * * * * * Press Room * Online Community * Online Store * PD Library * Privacy & Terms * Contact Us © 2024 Parkinson's Foundation The Parkinson's Foundation is a 501(c)(3) nonprofit organization. EIN: 13-1866796 contact@parkinson.org MAKE IT MONTHLY Turn your gift into a monthly gift to make a difference in the lives of people with Parkinson's all year. Yes, donate $20 monthly No thanks, complete my one-time gift