interland3.donorperfect.net
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104.18.12.201
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Submitted URL: https://transactions.chsc.org/
Effective URL: https://interland3.donorperfect.net/weblink/weblink.aspx?name=E353984&id=11
Submission: On March 25 via automatic, source certstream-suspicious — Scanned from DE
Effective URL: https://interland3.donorperfect.net/weblink/weblink.aspx?name=E353984&id=11
Submission: On March 25 via automatic, source certstream-suspicious — Scanned from DE
Form analysis 1 forms found in the DOM
POST FormSingleNM.aspx?name=E353984&id=11&formid=115
<form method="post" action="FormSingleNM.aspx?name=E353984&id=11&formid=115" language="javascript" onsubmit="javascript:return WebForm_OnSubmit();" id="thisForm">
<div class="aspNetHidden">
<input type="hidden" name="__EVENTTARGET" id="__EVENTTARGET" value="">
<input type="hidden" name="__EVENTARGUMENT" id="__EVENTARGUMENT" value="">
<input type="hidden" name="__LASTFOCUS" id="__LASTFOCUS" value="">
<input type="hidden" name="__VIEWSTATE" id="__VIEWSTATE"
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<legend>Donation Information </legend>
<div class="">
<div level="Field_giftPledgeAmount" class="form-group"><label>Amount</label>
<div id="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount_divRbl" class="form-group amount-group col-group">
<div id="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount_divButtonGroup" class="btn-group" data-toggle="buttons">
<div id="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount_divFirstColumn" class="col-xs-12 col-sm-6"><label class="btn btn-primary col-xs-12" onclick="rblGPOtherAmountChangedMOF(this)">
<div class="amount-wrapper">
<div class="amounts-left"><i class="fa fa-circle fa-3"></i><span data-group-other="Y"><input id="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount_ucGPOtherAmountRbl_0" type="radio"
name="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount:ucOtherAmountRbl" value="1000.00|$1,000|Y"><label for="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount_ucGPOtherAmountRbl_0"
class="amount-radio-option">$1,000</label></span></div>
</div>
</label><label class="btn btn-primary col-xs-12" onclick="rblGPOtherAmountChangedMOF(this)">
<div class="amount-wrapper">
<div class="amounts-left"><i class="fa fa-circle fa-3"></i><span data-group-other="Y"><input id="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount_ucGPOtherAmountRbl_1" type="radio"
name="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount:ucOtherAmountRbl" value="500.00|$500|Y"><label for="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount_ucGPOtherAmountRbl_1"
class="amount-radio-option">$500</label></span></div>
</div>
</label><label class="btn btn-primary col-xs-12" onclick="rblGPOtherAmountChangedMOF(this)">
<div class="amount-wrapper">
<div class="amounts-left"><i class="fa fa-circle fa-3"></i><span data-group-other="Y"><input id="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount_ucGPOtherAmountRbl_2" type="radio"
name="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount:ucOtherAmountRbl" value="250.00|$250|Y"><label for="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount_ucGPOtherAmountRbl_2"
class="amount-radio-option">$250</label></span></div>
</div>
</label></div>
<div id="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount_divSecondColumn" class="col-xs-12 col-sm-6"><label class="btn btn-primary col-xs-12" onclick="rblGPOtherAmountChangedMOF(this)">
<div class="amount-wrapper">
<div class="amounts-left"><i class="fa fa-circle fa-3"></i><span data-group-other="Y"><input id="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount_ucGPOtherAmountRbl_3" type="radio"
name="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount:ucOtherAmountRbl" value="100.00|$100|Y"><label for="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount_ucGPOtherAmountRbl_3"
class="amount-radio-option">$100</label></span></div>
</div>
</label><label class="btn btn-primary col-xs-12 other-amount" onclick="rblGPOtherAmountChangedMOF(this)">
<div class="amount-wrapper">
<div class="amounts-left"><i class="fa fa-circle fa-3"></i><span data-group-other="Y"><input id="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount_ucGPOtherAmountRbl_4" type="radio"
name="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount:ucOtherAmountRbl" value=""></span><input name="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount:ucGPOtherAmountTxt_4" type="text"
id="Part|1121|giftPledgeAmount|A|Y|giftPledgeAmount_ucGPOtherAmountTxt_4" class="otherAmountText" placeholder="Other" onblur="txtGPOtherAmountChangedMOF(this)" data-edited="False" size="5"></div>
</div>
</label></div>
</div>
</div>
</div>
</div>
<div class="">
<div level="Field_giftPledgeType" class="form-group"><label>Type of Donation</label>
<div id="Part|1121|giftPledgeType||N|giftPledgeType_pnlRblGiftPledge">
<div class="form-group"><label class="control radio"><input id="Part|1121|giftPledgeType||N|giftPledgeType_rdoGiftPledgeType_0" type="radio" name="Part|1121|giftPledgeType||N|giftPledgeType:Part|1121|giftPledgeType||N|giftPledgeType"
value="OTG" checked="checked" onclick="rblGiftPledgeTypeChangedMOF();"><span class="control-indicator"></span><span>One Time Donation</span></label><label class="control radio"><input
id="Part|1121|giftPledgeType||N|giftPledgeType_rdoGiftPledgeType_1" type="radio" name="Part|1121|giftPledgeType||N|giftPledgeType:Part|1121|giftPledgeType||N|giftPledgeType" value="RG"
onclick="rblGiftPledgeTypeChangedMOF();"><span class="control-indicator"></span><span>Recurring Donation</span></label></div>
</div>
</div>
</div>
<div class="form-inline label-up">
<div level="Field_giftPledgeFreq" class="form-group"><label id="lblGiftPledgeFreq111" style="display:none">Frequency</label>
<select name="Part|1121|giftPledgeFreq||N|giftPledgeFreq:ucDDLGPFreq" id="Part|1121|giftPledgeFreq||N|giftPledgeFreq_ucDDLGPFreq" class="form-control" onchange="ddlChangedGiftPledgeFrequencyMOF()" style="visibility:hidden;">
<option selected="selected" value="M|for|0|weeks|weekly">Monthly</option>
</select>
<input name="Part|1121|giftPledgeFreq||N|giftPledgeFreq:txtGPFreqFor" type="text" value="for" readonly="readonly" id="Part|1121|giftPledgeFreq||N|giftPledgeFreq_txtGPFreqFor"
style="background-color:Transparent;border-style:None;visibility:hidden;">
<input name="Part|1121|giftPledgeFreq||N|giftPledgeFreq:txtGPFreqIncrementBy" type="text" value="0" id="Part|1121|giftPledgeFreq||N|giftPledgeFreq_txtGPFreqIncrementBy" onblur="ddlChangedGiftPledgeFrequencyMOF()"
style="TEXT-ALIGN:right;visibility:hidden;">
<input name="Part|1121|giftPledgeFreq||N|giftPledgeFreq:txtGPFreqIncrementMessage" type="text" value="weeks = 0.00 weekly" readonly="readonly" id="Part|1121|giftPledgeFreq||N|giftPledgeFreq_txtGPFreqIncrementMessage"
style="background-color:Transparent;border-style:None;visibility:hidden;">
</div>
</div>
<div class="form-inline label-up">
<div level="Field_is_tribute" data-tribute-item-id="1121" class="form-group tribute-fields-trigger"><label class="control checkbox"><input id="Part|1121|is_tribute||N|is_tribute" type="checkbox" name="Part|1121|is_tribute||N|is_tribute"
data-check=""><span class="control-indicator"></span>I would like to dedicate this donation</label></div>
</div>
<div class="form-inline label-up">
<div level="Field_tribute_label" data-tribute-item-id="1121" style="display:none;" class="form-group tribute-fields"><label></label><span id="Part|1121|tribute_label||N|tribute_label" class="tribute_label"
name="Part|1121|tribute_label||N|tribute_label" fieldprompt="" disabled="disabled"> <br>Complete the following fields.<font size="2"> </font></span></div>
</div>
<div class="form-inline label-up">
<div level="Field_memory_honor" data-tribute-item-id="1121" style="display:none;" class="form-group tribute-fields">
<div class="glyphicon glyphicon-asterisk form-control-feedback"></div>
<font size="2"><label>Type of Tribute</label><label></label>
<select name="Part|1121|memory_honor||N|memory_honor:ucDDL" id="Part|1121|memory_honor||N|memory_honor_ucDDL" class="form-control" data-is-required="true" disabled="">
<option selected="selected" value=""></option>
<option value="M|In Memory Of|Y">In Memory Of</option>
<option value="H|In Honor Of|Y">In Honor Of</option>
</select>
</font>
</div>
</div>
<div class="form-inline label-up">
<div level="Field_tribute_name" data-tribute-item-id="1121" style="display:none;" class="form-group tribute-fields">
<div class="glyphicon glyphicon-asterisk form-control-feedback"></div>
<font size="2"><label>Tribute Name</label><input name="Part|1121|tribute_name||N|tribute_name" type="text" maxlength="75" id="Part|1121|tribute_name||N|tribute_name" class="form-control" fieldprompt="Tribute Name" disabled=""
data-is-required="true" readonly=""></font>
</div>
<div level="Field_tributeoccasion" class="form-group">
<font size="2"><label>My contribution is in recognition of the following occasion</label><label></label>
<select name="Part|1121|tributeoccasion||N|tributeoccasion:ucDDL" id="Part|1121|tributeoccasion||N|tributeoccasion_ucDDL" class="form-control">
<option selected="selected" value=""></option>
<option value="ANNIVERSARY|Anniversary|Y">Anniversary</option>
<option value="AWARDRECIPIENT|Award Recipient|Y">Award Recipient</option>
<option value="BIRTHDAY|Birthday|Y">Birthday</option>
<option value="SPEEDYRECOVERY|Speedy Recovery|Y">Speedy Recovery</option>
<option value="WEDDING|Wedding|Y">Wedding</option>
<option value="INMEMORY|In Memory|Y">In Memory</option>
<option value="OTHER|Other|Y">Other</option>
</select>
</font>
</div>
</div>
<div class="form-inline label-up">
<div level="Field_trib_lbl" data-tribute-item-id="1121" style="display:none;" class="form-group tribute-fields">
<font size="2"><label></label><span id="Part|1121|trib_lbl||N|trib_lbl" class="label-tag" name="Part|1121|trib_lbl||N|trib_lbl" fieldprompt="" disabled="disabled"> <br>Send Notification to: </span></font>
</div>
</div>
<div class="form-inline label-up">
<div level="Field_notif_title" data-tribute-item-id="1121" style="display:none;" class="form-group tribute-fields">
<font size="2"><label>Title</label><input name="Part|1121|notif_title||N|notif_title" type="text" maxlength="30" id="Part|1121|notif_title||N|notif_title" class="form-control" fieldprompt="Title" disabled="" readonly=""></font>
</div>
</div>
<div class="form-inline label-up">
<div level="Field_notif_first_name" data-tribute-item-id="1121" style="display:none;" class="form-group tribute-fields">
<font size="2"><label>First Name</label><input name="Part|1121|notif_first_name||N|notif_first_name" type="text" maxlength="50" id="Part|1121|notif_first_name||N|notif_first_name" class="form-control" fieldprompt="First Name"
disabled="" readonly=""></font>
</div>
</div>
<div class="form-inline label-up">
<div level="Field_notif_last_name" data-tribute-item-id="1121" style="display:none;" class="form-group tribute-fields">
<font size="2"><label>Last Name</label><input name="Part|1121|notif_last_name||N|notif_last_name" type="text" maxlength="50" id="Part|1121|notif_last_name||N|notif_last_name" class="form-control" fieldprompt="Last Name" disabled=""
readonly=""></font>
</div>
</div>
<div class="form-inline label-up">
<div level="Field_notif_address" data-tribute-item-id="1121" style="display:none;" class="form-group tribute-fields">
<font size="2"><label>Address</label><input name="Part|1121|notif_address||N|notif_address" type="text" maxlength="100" id="Part|1121|notif_address||N|notif_address" class="form-control" fieldprompt="Address" disabled="" readonly="">
</font>
</div>
</div>
<div class="form-inline label-up">
<div level="Field_notif_address2" data-tribute-item-id="1121" style="display:none;" class="form-group tribute-fields">
<font size="2"><label>Address 2</label><input name="Part|1121|notif_address2||N|notif_address2" type="text" maxlength="100" id="Part|1121|notif_address2||N|notif_address2" class="form-control" fieldprompt="Address 2" disabled=""
readonly=""></font>
</div>
</div>
<div class="form-inline label-up">
<div level="Field_notif_city" data-tribute-item-id="1121" style="display:none;" class="form-group tribute-fields">
<font size="2"><label>City</label><input name="Part|1121|notif_city||N|notif_city" type="text" maxlength="50" id="Part|1121|notif_city||N|notif_city" class="form-control" fieldprompt="City" disabled="" readonly=""></font>
</div>
</div>
<div class="form-inline label-up">
<div level="Field_notif_state" data-tribute-item-id="1121" style="display:none;" class="form-group tribute-fields">
<font size="2"><label>State/Province</label><label></label>
<select name="Part|1121|notif_state||N|notif_state:ucDDL" id="Part|1121|notif_state||N|notif_state_ucDDL" class="form-control" disabled="">
<option selected="selected" value=""></option>
<option value="AB|Alberta|Y">Alberta</option>
<option value="BC|British Columbia|Y">British Columbia</option>
<option value="MB|Manitoba|Y">Manitoba</option>
<option value="NB|New Brunswick|Y">New Brunswick</option>
<option value="NL|Newfoundland and Labrador|Y">Newfoundland and Labrador</option>
<option value="NT|Northwest Territories|Y">Northwest Territories</option>
<option value="NS|Nova Scotia|Y">Nova Scotia</option>
<option value="NU|Nunavut|Y">Nunavut</option>
<option value="ON|Ontario|Y">Ontario</option>
<option value="PE|Prince Edward Island|Y">Prince Edward Island</option>
<option value="QC|Quebec|Y">Quebec</option>
<option value="SK|Saskatchewan|Y">Saskatchewan</option>
<option value="YT|Yukon|Y">Yukon</option>
<option value="AL|Alabama|Y">Alabama</option>
<option value="AK|Alaska|Y">Alaska</option>
<option value="AZ|Arizona|Y">Arizona</option>
<option value="AR|Arkansas|Y">Arkansas</option>
<option value="AA|Armed Forces Americas|Y">Armed Forces Americas</option>
<option value="AE|Armed Forces Other|Y">Armed Forces Other</option>
<option value="AP|Armed Forces Pacific|Y">Armed Forces Pacific</option>
<option value="CA|California|Y">California</option>
<option value="CO|Colorado|Y">Colorado</option>
<option value="CT|Connecticut|Y">Connecticut</option>
<option value="DE|Delaware|Y">Delaware</option>
<option value="FL|Florida|Y">Florida</option>
<option value="GA|Georgia|Y">Georgia</option>
<option value="HI|Hawaii|Y">Hawaii</option>
<option value="ID|Idaho|Y">Idaho</option>
<option value="IL|Illinois|Y">Illinois</option>
<option value="IN|Indiana|Y">Indiana</option>
<option value="IA|Iowa|Y">Iowa</option>
<option value="KS|Kansas|Y">Kansas</option>
<option value="KY|Kentucky|Y">Kentucky</option>
<option value="LA|Louisiana|Y">Louisiana</option>
<option value="ME|Maine|Y">Maine</option>
<option value="MD|Maryland|Y">Maryland</option>
<option value="MA|Massachusetts|Y">Massachusetts</option>
<option value="MI|Michigan|Y">Michigan</option>
<option value="MN|Minnesota|Y">Minnesota</option>
<option value="MS|Mississippi|Y">Mississippi</option>
<option value="MO|Missouri|Y">Missouri</option>
<option value="MT|Montana|Y">Montana</option>
<option value="NE|Nebraska|Y">Nebraska</option>
<option value="NV|Nevada|Y">Nevada</option>
<option value="NH|New Hampshire|Y">New Hampshire</option>
<option value="NJ|New Jersey|Y">New Jersey</option>
<option value="NM|New Mexico|Y">New Mexico</option>
<option value="NY|New York|Y">New York</option>
<option value="NC|North Carolina|Y">North Carolina</option>
<option value="ND|North Dakota|Y">North Dakota</option>
<option value="OH|Ohio|Y">Ohio</option>
<option value="OK|Oklahoma|Y">Oklahoma</option>
<option value="OR|Oregon|Y">Oregon</option>
<option value="PA|Pennsylvania|Y">Pennsylvania</option>
<option value="PR|Puerto Rico|Y">Puerto Rico</option>
<option value="RI|Rhode Island|Y">Rhode Island</option>
<option value="SC|South Carolina|Y">South Carolina</option>
<option value="SD|South Dakota|Y">South Dakota</option>
<option value="TN|Tennessee|Y">Tennessee</option>
<option value="TX|Texas|Y">Texas</option>
<option value="UT|Utah|Y">Utah</option>
<option value="VT|Vermont|Y">Vermont</option>
<option value="VA|Virginia|Y">Virginia</option>
<option value="WA|Washington|Y">Washington</option>
<option value="DC|Washington DC|Y">Washington DC</option>
<option value="WV|West Virginia|Y">West Virginia</option>
<option value="WI|Wisconsin|Y">Wisconsin</option>
<option value="WY|Wyoming|Y">Wyoming</option>
</select>
</font>
</div>
</div>
<div class="form-inline label-up">
<div level="Field_notif_zip" data-tribute-item-id="1121" style="display:none;" class="form-group tribute-fields">
<font size="2"><label>Zip/Postal Code</label><input name="Part|1121|notif_zip||N|notif_zip" type="text" maxlength="10" id="Part|1121|notif_zip||N|notif_zip" class="form-control" fieldprompt="Zip/Postal Code" disabled="" readonly="">
</font>
</div>
</div>
<div class="form-inline label-up">
<div level="Field_notif_email" data-tribute-item-id="1121" style="display:none;" class="form-group tribute-fields">
<font size="2"><label>Email</label><input name="Part|1121|notif_email||N|notif_email" type="text" maxlength="75" id="Part|1121|notif_email||N|notif_email" class="form-control" fieldprompt="Email" disabled="" readonly=""></font>
</div>
</div>
</fieldset>
<fieldset id="section_Contact Information" level="Section1" class="wSectionTableCSS">
<font size="2">
<legend>Contact Information</legend>
<div class="form-inline label-up">
<div level="Field_first_name" class="form-group">
<div class="glyphicon glyphicon-asterisk form-control-feedback"></div><label>First Name</label>
<div id="first_name_pnl">
<input name="first_name:ucTxtBox" type="text" maxlength="30" id="first_name_ucTxtBox" onblur="SetCCName();" class="form-control">
</div>
</div>
<div level="Field_last_name" class="form-group">
<div class="glyphicon glyphicon-asterisk form-control-feedback"></div><label>Last Name</label>
<div id="last_name_pnl">
<input name="last_name:ucTxtBox" type="text" maxlength="30" id="last_name_ucTxtBox" onblur="SetCCName();" class="form-control">
</div>
</div>
</div>
<div class="form-inline label-up">
<div level="Field_opt_line" class="form-group"><label>Company Name</label><input name="opt_line" type="text" maxlength="100" id="opt_line" class="form-control" fieldprompt="Company Name"></div>
</div>
<div class="form-inline label-up">
<div level="Field_address" class="form-group">
<div class="glyphicon glyphicon-asterisk form-control-feedback"></div><label>Address</label>
<div id="address_pnl">
<input name="address:ucTxtBox" type="text" maxlength="30" id="address_ucTxtBox" class="form-control">
</div>
</div>
<div level="Field_address2" class="form-group"><label>Address 2</label><input name="address2" type="text" maxlength="30" id="address2" class="form-control" fieldprompt="Address 2"></div>
</div>
<div class="form-inline label-up">
<div level="Field_city" class="form-group">
<div class="glyphicon glyphicon-asterisk form-control-feedback"></div><label>City</label>
<div id="city_pnl">
<input name="city:ucTxtBox" type="text" maxlength="30" id="city_ucTxtBox" class="form-control">
</div>
</div>
<div level="Field_state" class="form-group">
<div class="glyphicon glyphicon-asterisk form-control-feedback"></div><label>State/Province</label>
<div id="state_pnl">
<select name="state:ucDDL" id="state_ucDDL" class="form-control">
<option selected="selected" value=""></option>
<option value="AL|Alabama|Y">Alabama</option>
<option value="AK|Alaska|Y">Alaska</option>
<option value="AB|Alberta|Y">Alberta</option>
<option value="AZ|Arizona|Y">Arizona</option>
<option value="AR|Arkansas|Y">Arkansas</option>
<option value="AA|Armed Forces Americas|Y">Armed Forces Americas</option>
<option value="AE|Armed Forces Other|Y">Armed Forces Other</option>
<option value="AP|Armed Forces Pacific|Y">Armed Forces Pacific</option>
<option value="BC|British Columbia|Y">British Columbia</option>
<option value="CA|California|Y">California</option>
<option value="CO|Colorado|Y">Colorado</option>
<option value="CT|Connecticut|Y">Connecticut</option>
<option value="DE|Delaware|Y">Delaware</option>
<option value="FL|Florida|Y">Florida</option>
<option value="GA|Georgia|Y">Georgia</option>
<option value="HI|Hawaii|Y">Hawaii</option>
<option value="ID|Idaho|Y">Idaho</option>
<option value="IL|Illinois|Y">Illinois</option>
<option value="IN|Indiana|Y">Indiana</option>
<option value="IA|Iowa|Y">Iowa</option>
<option value="KS|Kansas|Y">Kansas</option>
<option value="KY|Kentucky|Y">Kentucky</option>
<option value="LA|Louisiana|Y">Louisiana</option>
<option value="ME|Maine|Y">Maine</option>
<option value="MB|Manitoba|Y">Manitoba</option>
<option value="MD|Maryland|Y">Maryland</option>
<option value="MA|Massachusetts|Y">Massachusetts</option>
<option value="MI|Michigan|Y">Michigan</option>
<option value="MN|Minnesota|Y">Minnesota</option>
<option value="MS|Mississippi|Y">Mississippi</option>
<option value="MO|Missouri|Y">Missouri</option>
<option value="MT|Montana|Y">Montana</option>
<option value="NE|Nebraska|Y">Nebraska</option>
<option value="NV|Nevada|Y">Nevada</option>
<option value="NB|New Brunswick|Y">New Brunswick</option>
<option value="NH|New Hampshire|Y">New Hampshire</option>
<option value="NJ|New Jersey|Y">New Jersey</option>
<option value="NM|New Mexico|Y">New Mexico</option>
<option value="NY|New York|Y">New York</option>
<option value="NL|Newfoundland and Labrador|Y">Newfoundland and Labrador</option>
<option value="NC|North Carolina|Y">North Carolina</option>
<option value="ND|North Dakota|Y">North Dakota</option>
<option value="NT|Northwest Territories|Y">Northwest Territories</option>
<option value="NS|Nova Scotia|Y">Nova Scotia</option>
<option value="NU|Nunavut|Y">Nunavut</option>
<option value="OH|Ohio|Y">Ohio</option>
<option value="OK|Oklahoma|Y">Oklahoma</option>
<option value="ON|Ontario|Y">Ontario</option>
<option value="OR|Oregon|Y">Oregon</option>
<option value="PA|Pennsylvania|Y">Pennsylvania</option>
<option value="PE|Prince Edward Island|Y">Prince Edward Island</option>
<option value="PR|Puerto Rico|Y">Puerto Rico</option>
<option value="QC|Quebec|Y">Quebec</option>
<option value="RI|Rhode Island|Y">Rhode Island</option>
<option value="SK|Saskatchewan|Y">Saskatchewan</option>
<option value="SC|South Carolina|Y">South Carolina</option>
<option value="SD|South Dakota|Y">South Dakota</option>
<option value="TN|Tennessee|Y">Tennessee</option>
<option value="TX|Texas|Y">Texas</option>
<option value="UT|Utah|Y">Utah</option>
<option value="VT|Vermont|Y">Vermont</option>
<option value="VA|Virginia|Y">Virginia</option>
<option value="WA|Washington|Y">Washington</option>
<option value="DC|Washington DC|Y">Washington DC</option>
<option value="WV|West Virginia|Y">West Virginia</option>
<option value="WI|Wisconsin|Y">Wisconsin</option>
<option value="WY|Wyoming|Y">Wyoming</option>
<option value="YT|Yukon|Y">Yukon</option>
</select>
</div>
</div>
<div level="Field_zip" class="form-group">
<div class="glyphicon glyphicon-asterisk form-control-feedback"></div><label>Zip/Postal Code</label>
<div id="zip_pnl">
<input name="zip:ucTxtBox" type="text" maxlength="10" id="zip_ucTxtBox" class="form-control">
</div>
</div>
</div>
<div class="form-inline label-up">
<div level="Field_home_phone" class="form-group"><label>Home Phone</label>
<div id="home_phone_pnlPhone">
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</form>Text Content
One of the greatest honors we receive at Cleveland Hearing & Speech Center is when parents trust us enough to provide services for their whole family. Bradford and Clayton’s parents chose CHSC when they were toddlers for early intervention speech therapy and Bradford returned to CHSC as a young adult after receiving a dyslexia diagnosis. The brothers both graduated college in four years and are enjoying successful careers in education and human resources! Bradford and Clayton credit their many successes to the early intervention and ongoing support from Cleveland Hearing & Speech Center! Donation Information Amount $1,000 $500 $250 $100 Type of Donation One Time DonationRecurring Donation Frequency Monthly I would like to dedicate this donation Complete the following fields. Type of Tribute In Memory Of In Honor Of Tribute Name My contribution is in recognition of the following occasion Anniversary Award Recipient Birthday Speedy Recovery Wedding In Memory Other Send Notification to: Title First Name Last Name Address Address 2 City State/Province Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Alabama Alaska Arizona Arkansas Armed Forces Americas Armed Forces Other Armed Forces Pacific California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Zip/Postal Code Email Contact Information First Name Last Name Company Name Address Address 2 City State/Province Alabama Alaska Alberta Arizona Arkansas Armed Forces Americas Armed Forces Other Armed Forces Pacific British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland and Labrador North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Yukon Zip/Postal Code Home Phone Cell Phone Work Phone Email Your entry is not a valid email address! Help Us Cover Costs Simply leave "Yes!" checked below to ensure that 100% of your intended donation is available for our mission. Yes! I want $0.00 to go to Cleveland Hearing & Speech Center and I will donate $0.00.No. I will donate $0.00 and Cleveland Hearing & Speech Center will cover the processing costs. Payment Information Payment Options Credit Card Bank Account Credit Card Information Card Holder Name Visa MasterCard Discover Card Account Number Expiration Date Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 24 25 26 27 28 29 30 31 32 33 34 Security Code Billing Address Same As Above Address City State/Province Alabama Alaska Alberta Arizona Arkansas Armed Forces Americas Armed Forces Other Armed Forces Pacific British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland and Labrador North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Yukon Zip/Postal Code Email Your entry is not a valid email address! Next Privacy Policy We take precautions to protect your information. We collect credit card or bank account information, names, addresses, and other data related to your transaction when you make a payment through our site. We use this information to process your payment. Terms/Conditions By submitting your payment, you authorize us to charge the account above for the amount specified in the Transaction Amount field. Account information for Recurring Pledges/Monthly Giving is encrypted and stored securely via SafeSave™ for automatic processing of your future payments. Notify us at anytime if you wish to discontinue your pledge. ©2024 SofterWare, Inc. v.2024.01-C