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<form class="js-form preferences" method="POST" action="" novalidate="novalidate">
  <fieldset class="field-group">
    <legend class="is-vishidden">Profile Information</legend>
    <div class="preferences__group">
      <div class="field preferences__field">
        <label for="first-name" class="label label--preferences-field">First Name</label>
        <input class="input" id="first-name" name="Name_FirstName" type="text" value="Danielle" maxlength="50">
      </div>
      <div class="field preferences__field">
        <label for="last-name" class="label label--preferences-field">Last Name</label>
        <input class="input" id="last-name" name="Name_LastName" type="text" value="Lockmiller" maxlength="50">
      </div>
      <div class="field preferences__field js-validation-field" id="js-validation-field--3457843862566">
        <label for="email-address" class="label label--preferences-field">Email Address</label>
        <input class="input" id="email-address" name="Cons_PrimaryEmail" type="email" required="" value="dlockmiller@laredopetro.com" aria-required="true" maxlength="254" data-validation-field-id="js-validation-field--3457843862566">
        <div class="validation-field__errors validation-field__errors--default"></div>
      </div>
      <div class="field preferences__field js-validation-field" data-validation-pattern-message="Please enter a valid date" id="js-validation-field--2652521183589">
        <label for="birthday" class="label label--preferences-field">Birthday</label>
        <input class="input js-birthdate" id="birthday" name="Cons_BirthDate" type="text" placeholder="MM/DD/YYYY" value=""
          pattern="^(((0[1-9]|1[012])/(0[1-9]|1\d|2[0-8])|(0[13456789]|1[012])/(29|30)|(0[13578]|1[02])/31)/(19|[2-9]\d)\d{2}|02/29/((19|[2-9]\d)(0[48]|[2468][048]|[13579][26])|(([2468][048]|[3579][26])00)))$"
          data-validation-field-id="js-validation-field--2652521183589">
        <div class="validation-field__errors validation-field__errors--default"></div>
      </div>
    </div>
  </fieldset>
  <fieldset class="field-group">
    <legend class="field-group__label">General Make-A-Wish News and Updates</legend>
    <ul class="field-list">
      <li class="field field-list__item">
        <div class="input-wrapper--checkbox">
          <input class="input input--checkbox js-checkbox" id="receive-updates" name="subscribe_to_amer" type="checkbox" checked="" value="yes">
          <label for="receive-updates" class="label">Receive inspiring wish stories, stay informed about Make-A-Wish news and the impact of our work, and learn how you can help grant wishes.</label>
        </div>
      </li>
    </ul>
  </fieldset>
  <fieldset class="field-group">
    <legend class="field-group__label">Local Chapters' News and Updates</legend>
    <ul class="field-list">
      <li class="field field-list__item">
        <div class="js-checkbox-parent-container input-wrapper--checkbox section--expanded">
          <input class="input input--checkbox js-checkbox js-checkbox-parent" id="maw-center-1036" name="maw-center-1036" type="checkbox" value="true" checked="">
          <label for="maw-center-1036" class="label"> Make-A-Wish Oklahoma </label>
          <input class="input" id="orig-maw-center-1036" name="orig-maw-center-1036" value="True" readonly="yes" style="display: none;">
        </div>
      </li>
    </ul>
  </fieldset>
  <fieldset class="field-group">
    <legend class="field-group__label">Unsubscribe</legend>
    <ul class="field-list">
      <li class="field field-list__item">
        <div class="input-wrapper--checkbox">
          <input class="input input--checkbox js-unsubscribe-all" id="unsubscribe-from-all" name="unsubscribe-from-all" type="checkbox" value="yes">
          <label for="unsubscribe-from-all" class="label">Opt out of all email from Make-A-Wish</label>
          <input class="input " id="orig-subscriber-status" name="orig-subscriber-status" type="hidden" value="checked" readonly="yes" style="display: none;">
        </div>
      </li>
    </ul>
  </fieldset>
  <button type="submit" class="button"> Save Preferences </button>
</form>

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MAKE-A-WISH EMAIL PREFERENCES

Profile Information
First Name
Last Name
Email Address

Birthday

General Make-A-Wish News and Updates
 * Receive inspiring wish stories, stay informed about Make-A-Wish news and the
   impact of our work, and learn how you can help grant wishes.

Local Chapters' News and Updates
 * Make-A-Wish Oklahoma

Unsubscribe
 * Opt out of all email from Make-A-Wish

Save Preferences

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1702 E. Highland Ave. Suite 400, Phoenix, AZ 85016 | (602) 279-9474

Make-A-Wish Foundation of America is an Arizona nonprofit corporation exempt
from federal income tax under Section 501(c)(3) of the Internal Revenue Code.

Federal Identification Number (EIN): 86-0481941

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