secure.afmda.org
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74.123.152.164
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Submitted URL: https://rs1.netatlantic.com/t/8205973/49995790/159197/4/
Effective URL: https://secure.afmda.org/site/Donation2?df_id=2000&%3B2000.donation=form1&%3Bs_src=GNRLWEB&%3BFURL=UR&utm_source...
Submission: On December 22 via api from US — Scanned from DE
Effective URL: https://secure.afmda.org/site/Donation2?df_id=2000&%3B2000.donation=form1&%3Bs_src=GNRLWEB&%3BFURL=UR&utm_source...
Submission: On December 22 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: process — POST https://secure.afmda.org/site/Donation2
<form name="process" id="ProcessForm" action="https://secure.afmda.org/site/Donation2" method="post" onsubmit="return checkDoubleClick();">
<div class="donation-form-container responsive">
<script type="text/javascript">
<!--
function reloadPage() {
window.location.reload(true);
}
function testAjax() {
var xmlHttp = null;
// Opera 8.0+, Firefox, Chrome, Safari
try {
xmlHttp = new XMLHttpRequest();
} catch (e) {
// Internet Explorer Browsers
try {
xmlHttp = new ActiveXObject("Msxml2.XMLHTTP");
} catch (e) {
try {
xmlHttp = new ActiveXObject("Microsoft.XMLHTTP");
} catch (e) {
return false;
}
}
}
xmlHttp.open('POST', 'AjaxHelper;jsessionid=00000000.app20102a?NONCE_TOKEN=5ECCC4CDEC97052C45F1B2C7A59526FC', true);
xmlHttp.send();
}
addOnLoadHandler(testAjax);
//
-->
</script>
<div class="donation-form-content">
<input type="hidden" name="user_donation_amt" id="user_donation_amt" value="">
<input type="hidden" name="company_min_matching_amt" id="company_min_matching_amt" value="">
<input type="hidden" name="currency_locale" id="currency_locale" value="en_US">
<div class="form-row">
<div class="html-caption-container">
<div class="form-title-content">
<img style="width: 100%" src="https://secure.afmda.org/images/content/pagebuilder/MicrosoftTeams-image__44_.png">
<h1> Saving lives is in our blood. <span class="red">And it's in yours too.</span>
</h1>
<p style="margin-top: 30px"> AFMDA is a 501(c)(3) tax-exempt organization. Our federal tax ID number is 13-1790719. All donations are securely protected. </p>
<div class="required-text">
<p style="margin-top: 30px">
<span style="color: red">*</span> = Required fields
</p>
</div>
</div>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<h2 class="section-header-container">
<span id="titleFrequency">Donation Amount</span>
</h2>
<style>
div.donation-level-container {
float: left;
margin-right: 20px;
}
label+div.donation-level-user-entered {
margin-left: 4px;
display: inline-block;
margin-top: 0px;
}
input[type="radio"] {
margin: 5px 0 0 0;
}
div.donation-level-input-container,
div.generic-repeat-label-checkbox-container {
padding: 0 0 10px;
}
div.responsive div.form-content {
margin-bottom: 0;
margin-right: 0;
margin-top: 0;
}
#billing_first_name_row,
#billing_middle_name_row,
#billing_last_name_row {
float: left;
margin-right: 10px;
}
#billing_addr_street1_row {
clear: both;
}
div.donation-level-input-container,
div.generic-repeat-label-checkbox-container {
padding: 0;
}
div.donation-level-user-entered {
display: block;
float: right;
margin-left: 5px;
}
div.donation-level-amount-container {
margin-top: 5px;
}
div.donation-level-label-container {
margin-top: 3px;
}
div.button-container {
border-top: 0 none;
margin-top: 0;
padding-top: 0;
}
#pstep_cancel {
display: none;
}
div.button-container {
display: inline-block;
}
div.form-row {
margin-top: 15px;
}
</style>
<br>
</div>
</div>
<div id="level_standard_row">
<div class="don-standard-levels form-row">
<div class="levels-label">
</div>
<div id="level_standard_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 an amount</span>
<div class="donation-level-general-ask">
</div>
<div class="donation-levels">
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded2761" value="2761" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
<label for="level_standardexpanded2761" onclick="">
<div class="donation-level-label-container"> $2,500 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_2761expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded2762" value="2762" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
<label for="level_standardexpanded2762" onclick="">
<div class="donation-level-label-container"> $1,000 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_2762expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded2763" value="2763" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
<label for="level_standardexpanded2763" onclick="">
<div class="donation-level-label-container"> $500 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_2763expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded2804" value="2804" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
<label for="level_standardexpanded2804" onclick="">
<div class="donation-level-label-container"> $360 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_2804expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded2764" value="2764" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
<label for="level_standardexpanded2764" onclick="">
<div class="donation-level-label-container"> $100 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_2764expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded2765" value="2765" checked="checked" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
<label for="level_standardexpanded2765" onclick="">
<div class="donation-level-label-container"> $54 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_2765expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded2766" value="2766" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
<label for="level_standardexpanded2766" onclick="">
<div class="donation-level-label-container"> $36 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_2766expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded2767" value="2767" onclick="evalMatchingGift(document.getElementById('level_standardexpanded2767amount').value);
updateDonorCoverAmount(document.getElementById('level_standardexpanded2767amount').value);">
<label for="level_standardexpanded2767" onclick="" style="display: none;">
<div class="donation-level-label-container"> Other </div>
</label>
<div class="donation-level-user-entered"><label for="level_standardexpanded2767amount"><span class="aural-only">Enter amount</span></label><input type="text" name="level_standardexpanded2767amount"
id="level_standardexpanded2767amount" value="" size="12" maxlength="50"
onfocus="var el = document.getElementById ('level_standardexpanded2767');if (el) el.click(); fire_obs_comp_event('level_standardexpanded2767amount', this, event);evalMatchingGift(value); "
onchange="fire_obs_comp_event('level_standardexpanded2767amount', this, event);evalMatchingGift(value);" onkeyup="fire_obs_comp_event('level_standardexpanded2767amount', this, event);evalMatchingGift(value);"
onblur="fire_obs_comp_event('level_standardexpanded2767amount', this);updateDonorCoverAmount(value);" placeholder="Other"></div>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_2767expandedsubmit" value="true">
</div>
</div>
</div>
</div>
<script type="text/javascript">
Y.use("jquery-ui", function(Y) {
jQuery(function() {
// subscribe observables
jQuery('div.donation-level-element-container').find('input[type="radio"]').each(function() {
var syncAction = function(obj) {
if (obj.is(':checked')) {
obj.closest('div.donation-level-container').addClass('selected');
} else {
obj.closest('div.donation-level-container').removeClass('selected');
};
return arguments.callee;
}(jQuery(this));
jQuery(this).click(function() {
jQuery('div.donation-level-container').removeClass('selected');
syncAction(jQuery(this));
});
});
});
});
</script><noscript> </noscript>
</div>
<div class="levels-gift-aid">
</div>
<input type="hidden" name="level_standardsubmit" id="level_standardsubmit" value="true">
<script type="text/javascript">
function updateDonorCoverAmount(gift) {
if (typeof updateAmount !== "undefined") {
updateAmount(gift);
}
};
function evalMatchingGift(gift) {}
</script><noscript> </noscript>
</div>
<div id="frequencyContainer">
<div class="donation-level-container-generic-repeat form-input">
<p id="oneTimeMessage">You have chosen a one-time gift. You could make an even greater impact by giving monthly.</p>
<div class="generic-repeat-label-checkbox-container makeMonthlyParent">
<input type="checkbox" name="level_standardauto_repeatname" id="level_standardauto_repeatname" onclick="fire_obs_comp_event('level_standardauto_repeat', this);" onkeypress="fire_obs_comp_event('level_standardauto_repeat', this);">
<label for="level_standardauto_repeatname" style="font-weight: initial;"> I want to make a monthly gift. </label>
</div>
<div class="monthlyMessage hide">Yes, I'd like to make an ongoing impact in Israel by becoming a sustaining donor. Please charge the donation amount I've designated to my credit card each month.</div>
<input type="hidden" name="level_standardauto_repeatsubmit" id="level_standardauto_repeatsubmit" value="true">
</div>
</div>
<script type="text/javascript">
// subscribe listeners to make an ajax call to the server to calculate the total amount
Y.use('jquery-noconflict', function() {
var fetchAmountFunc = function() {
// find all the select, textarea, input, etc... and format them into key=val pairs.
var params = jQuery('#level_standard_row :input').serialize();
// parse the path and append the key/value pairs above to the url
var url = 'https://secure.afmda.org/site/Donation2?idb=859315647&level_standardajaxfetch=true&df_id=2000&2000.donation=form1&mfc_pref=T&level_standardtotalcalculateBtn=true';
var index = url.indexOf("?");
var path = url.substring(0, index);
var args = url.substring(index + 1, url.length);
args += '&' + params;
var recurringGiftTermsContainer = jQuery('#recurring_gift_terms_acceptance_message_container');
if (recurringGiftTermsContainer && recurringGiftTermsContainer.length > 0) {
jQuery.ajax(path, {
data: args,
success: function(data) {
jQuery('#recurring_gift_terms_acceptance_message_container').trigger("recurringTermsChange");
}
});
}
};
jQuery('#level_standard_row :input[type=text]').blur(function() {
fetchAmountFunc();
});
jQuery('#level_standard_row input:checkbox, #level_standard_row input:radio').click(function() {
fetchAmountFunc();
});
jQuery('#level_standard_row select').change(function() {
fetchAmountFunc();
});
// call it on page load
fetchAmountFunc();
});
</script><noscript> </noscript>
</div>
<div class="form-row">
<div class="html-caption-container">
<p id="general_ambulanceCampaign">Learn about how you, your family, synagogue, or community can help provide an urgently needed ambulance and support
<a href="https://afmda.org/donate/ambulance-emergency/" target="_blank">AFMDA’s Ambulance Emergency Campaign</a>.</p>
<style type="text/css">
#general_ambulanceCampaign {
font-size: 18px;
margin-top: 10px;
}
#general_ambulanceCampaign a,
#general_ambulanceCampaign a:link,
#general_ambulanceCampaign a:visited,
#general_ambulanceCampaign a:hover,
#general_ambulanceCampaign a:active {
color: #d11242;
text-decoration: underline;
}
</style>
</div>
</div>
<h2 class="section-header-container"> Tribute Cards (optional) </h2>
<div id="tribute_show_honor_fields_row" class="form-row form-checkbox">
<div class="form-content">
<input type="checkbox" name="tribute_show_honor_fieldsname" id="tribute_show_honor_fieldsname" onclick="fire_obs_comp_event('tribute_show_honor_fields', this);">
<label for="tribute_show_honor_fieldsname">I would like to make this donation in honor or in memory of someone.</label>
<input type="hidden" name="tribute_show_honor_fieldssubmit" id="tribute_show_honor_fieldssubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_show_honor_fields', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_show_honor_fields_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('tribute_show_honor_fieldsname')) {
document.getElementById('tribute_show_honor_fieldsname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('tribute_show_honor_fieldsname')) {
return document.getElementById('tribute_show_honor_fieldsname').checked;
}
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_type_row" class="form-row form-selectlist" style="display: none;">
<div class="form-content">
<label class="FormLabel" for="tribute_type">Honor Gift Type</label>
<select name="tribute_type" id="tribute_type" size="1">
<option>Get Well</option>
<option value="tribute_type_value1">In Memory of</option>
<option value="tribute_type_value2">In Honor of</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('tribute_type', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_type_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="tribute_typesubmit_skip" id="tribute_typesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_type', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_type_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_type'));
function tribute_type_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('tribute_type', src);
}
}
var el = document.getElementById('tribute_type');
if (el) {
Utils.addEvent(el, 'change', tribute_type_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="honoree_title_row" class="form-row form-selectlist" style="display: none;">
<div class="form-content">
<label class="FormLabel" for="honoree_title">Honoree Title</label>
<select name="honoree_title" id="honoree_title" size="1">
<option></option>
<option value="Mr.">Mr.</option>
<option value="Ms.">Ms.</option>
<option value="Mrs.">Mrs.</option>
<option value="Miss">Miss</option>
<option value="Dr.">Dr.</option>
<option value="Mx.">Mx.</option>
<option value="Rabbi">Rabbi</option>
<option value="Rev.">Rev.</option>
<option value="Pastor">Pastor</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('honoree_title', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('honoree_title_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="honoree_titlesubmit_skip" id="honoree_titlesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('honoree_title', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('honoree_title_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('honoree_title'));
function honoree_title_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('honoree_title', src);
}
}
var el = document.getElementById('honoree_title');
if (el) {
Utils.addEvent(el, 'change', honoree_title_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_honoree_first_name_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_honoree_first_namename">Honoree First Name</label>
<input type="text" name="tribute_honoree_first_namename" id="tribute_honoree_first_namename" value="" maxlength="50">
<input type="hidden" name="tribute_honoree_first_namesubmit_skip" id="tribute_honoree_first_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_honoree_first_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_honoree_first_name_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_honoree_first_name'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_honoree_last_name_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_honoree_last_namename">Honoree Last Name</label>
<input type="text" name="tribute_honoree_last_namename" id="tribute_honoree_last_namename" value="" maxlength="50">
<input type="hidden" name="tribute_honoree_last_namesubmit_skip" id="tribute_honoree_last_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_honoree_last_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_honoree_last_name_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_honoree_last_name'));
</script><noscript> </noscript>
</div>
</div>
<div id="send_ecard_row" class="form-row form-checkbox yesToTribute" style="pointer-events: initial; color: inherit; display: none;">
<div class="form-content">
<input type="checkbox" name="send_ecardname" id="send_ecardname" onclick="fire_obs_comp_event('send_ecard', this);">
<label for="send_ecardname">Yes, I would like to send an eCard.</label>
<input type="hidden" name="send_ecardsubmit" id="send_ecardsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('send_ecard', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('send_ecard_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('send_ecardname')) {
document.getElementById('send_ecardname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('send_ecardname')) {
return document.getElementById('send_ecardname').checked;
}
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<div class="printCardoptions TribMailFields" style="display: none;">
<div class="col-xs-12 col-sm-4 col-med-4 col-lrg-4" style="display: none;">
<img class="card-memory img-responsive" alt="In Memory card. We Remember." src="../images/content/pagebuilder/afmda-tribute-cards-2020-IM-WeRemember.jpg">
</div>
<div class="col-xs-12 col-sm-4 col-med-4 col-lrg-4" style="display: none;">
<img class="card-honor img-responsive" alt="In Honor card. Ambulance." src="../images/content/pagebuilder/afmda-tribute-cards-2020-IH-ambulance-360px.jpg">
</div>
<div class="col-xs-12 col-sm-4 col-med-4 col-lrg-4">
<img class="card-getwell img-responsive" alt="Other card. Get Well." src="../images/content/pagebuilder/afmda-tribute-cards-2020-Other-600px.jpg">
</div>
</div>
</div>
</div>
<div id="ecard_send_date_row" class="form-row form-date TribEmailFields" style="display: none;">
<div class="form-content">
<label for="ecard_send_date_MONTH">
<span class="label-text">Send eCard on</span><span class="aural-only">Select month of credit card</span>
</label>
<label for="ecard_send_date_YEAR"><span class="aural-only">Select Expiration Year</span></label>
<div class="date-input-container">
<label for="ecard_send_date_MONTH"><span style="display:none;">Month</span></label>
<label for="ecard_send_date_DAY"><span style="display:none;">Day</span></label>
<label for="ecard_send_date_YEAR"><span style="display:none;">Year</span></label>
<select name="ecard_send_date_MONTH" id="ecard_send_date_MONTH" title="Month">
<option value="1">Jan</option>
<option value="2">Feb</option>
<option value="3">Mar</option>
<option value="4">Apr</option>
<option value="5">May</option>
<option value="6">Jun</option>
<option value="7">Jul</option>
<option value="8">Aug</option>
<option value="9">Sep</option>
<option value="10">Oct</option>
<option value="11">Nov</option>
<option value="12" selected="selected">Dec</option>
</select>
<select name="ecard_send_date_DAY" id="ecard_send_date_DAY" title="Day">
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21" selected="selected">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select>
<select name="ecard_send_date_YEAR" id="ecard_send_date_YEAR" title="Year">
<option value="2033">2033</option>
<option value="2032">2032</option>
<option value="2031">2031</option>
<option value="2030">2030</option>
<option value="2029">2029</option>
<option value="2028">2028</option>
<option value="2027">2027</option>
<option value="2026">2026</option>
<option value="2025">2025</option>
<option value="2024">2024</option>
<option value="2023" selected="selected">2023</option>
</select>
</div>
<input type="hidden" name="ecard_send_datesubmit" id="ecard_send_datesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('ecard_send_date', 'input');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('ecard_send_date_row', _display);
disable_submit_flag('ecard_send_datesubmit', _hidden);
}
comp.disable = function(_disabled) {
disable_element('ecard_send_date_MONTH', _disabled);
disable_element('ecard_send_date_DAY', _disabled);
disable_element('ecard_send_date_YEAR', _disabled);
disable_element('ecard_send_date_HOUR12', _disabled);
disable_element('ecard_send_date_HOUR24', _disabled); //For UK, 24 hour clock used
disable_element('ecard_send_date_MINUTE', _disabled);
disable_element('ecard_send_date_AMPM', _disabled);
}
</script><noscript> </noscript>
</div>
</div>
<div id="ecard_recpients_row" class="form-row form-text TribEmailFields" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="ecard_recpientsname">Recipient email addresses. Separate multiple addresses with a comma or a new line</label>
<p id="ecardrecipients" style="margin-top: 8px; color: #d11242">Maximum 255 characters</p>
<textarea cols="60" rows="4" name="ecard_recpientsname" id="ecard_recpientsname" maxlength="255"></textarea>
<input type="hidden" name="ecard_recpientssubmit" id="ecard_recpientssubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('ecard_recpients', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('ecard_recpients_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="e_card_copy_sender_row" class="form-row form-checkbox TribEmailFields" style="display: none;">
<div class="form-content">
<input type="checkbox" name="e_card_copy_sendername" id="e_card_copy_sendername" onclick="fire_obs_comp_event('e_card_copy_sender', this);">
<label for="e_card_copy_sendername">Yes, send me a copy of the eCard.</label>
<input type="hidden" name="e_card_copy_sendersubmit" id="e_card_copy_sendersubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('e_card_copy_sender', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('e_card_copy_sender_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('e_card_copy_sendername')) {
document.getElementById('e_card_copy_sendername').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('e_card_copy_sendername')) {
return document.getElementById('e_card_copy_sendername').checked;
}
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
</div>
</div>
<div class="custom-field-container form-row mailCardParent yesToTribute" id="send_mcard_row" style="pointer-events: initial; color: inherit; display: none;">
<div class="form-content">
<div class="form-input-label-block">
<fieldset>
<input type="checkbox" name="mail_tribute_card_radio" id="mail_tribute_card_radio" value="true">
<label class="custom-element-checkbox-label" for="mail_tribute_card_radio">Yes, send card by mail.</label>
</fieldset><label for="mail_tribute_card_dropdown">Mail Tribute Card</label>
</div>
<input type="hidden" name="mail_tribute_cardsubmit" id="mail_tribute_cardsubmit" value="true">
</div>
</div>
<div id="select_grid_row" class="form-row form-text TribEmailFields" style="display: none;">
<div class="form-content">
<label for="select_gridname">eCard</label>
<input type="hidden" name="stationery_layout_chooser" id="stationery_layout_chooser" value="true">
<div class="layout-chooser-container clearfix">
<div class="layout-choice-thumbnail-container">
<label class="layout-choice-thumbnail-label" for="stationery_layout_id_1301">
<img src="../images/content/pagebuilder/afmda-tribute-cards-2020-Other-600px.jpg" alt="Get Well" border="0">
</label>
<input type="radio" name="stationery_layout_id" id="stationery_layout_id_1301" value="1301" checked="checked">
</div>
<div class="layout-choice-thumbnail-container" style="display: none;">
<label class="layout-choice-thumbnail-label" for="stationery_layout_id_1303">
<img src="../images/content/pagebuilder/afmda-tribute-cards-2020-IH-ambulance-360px.jpg" alt="In Honor" border="0">
</label>
<input type="radio" name="stationery_layout_id" id="stationery_layout_id_1303" value="1303">
</div>
<div class="layout-choice-thumbnail-container" style="display: none;">
<label class="layout-choice-thumbnail-label" for="stationery_layout_id_1302">
<img src="../images/content/pagebuilder/afmda-tribute-cards-2020-IM-WeRemember.jpg" alt="In Memory" border="0">
</label>
<input type="radio" name="stationery_layout_id" id="stationery_layout_id_1302" value="1302">
</div>
</div>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('select_grid', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('select_grid_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script><noscript> </noscript>
<input type="hidden" name="select_gridsubmit" id="select_gridsubmit" value="true">
</div>
</div>
<div id="tribute_ecard_subject_row" class="form-row form-text TribEmailFields" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_ecard_subjectname">eCard Subject</label>
<input type="text" name="tribute_ecard_subjectname" id="tribute_ecard_subjectname" value="A donation has been made in tribute" maxlength="50">
<input type="hidden" name="tribute_ecard_subjectsubmit" id="tribute_ecard_subjectsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_ecard_subject', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_ecard_subject_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_ecard_message_row" class="form-row form-text TribEmailFields" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_ecard_messagename">Card Message</label>
<textarea cols="60" rows="4" name="tribute_ecard_messagename" id="tribute_ecard_messagename" maxlength="255"></textarea>
<p id="charNum" style="margin-top: 8px; color: #d11242"></p>
<input type="hidden" name="tribute_ecard_messagesubmit" id="tribute_ecard_messagesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_ecard_message', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_ecard_message_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="ecard-preview" class="form-row form-button" style="display: none;">
<div class="form-content"><button class="step-button action-button" type="button" name="ecardPreviewBtn" id="ecardPreviewBtn">Preview my eCard</button></div>
</div>
<div id="inHonorEcardPreviewContainer" style="display: none;">
<table id="bodyTable">
<tbody>
<tr>
<td align="center" valign="top" id="bodyCell">
<table border="0" cellpadding="0" cellspacing="0" width="100%" class="templateContainer">
<tbody>
<tr>
<td valign="top" id="templateHeader">
<table border="0" cellpadding="0" cellspacing="0" width="100%" class="mcnImageBlock" style="min-width: 100%">
<tbody class="mcnImageBlockOuter">
<tr>
<td valign="top" style="padding: 9px" class="mcnImageBlockInner">
<table align="left" width="100%" border="0" cellpadding="0" cellspacing="0" class="mcnImageContentContainer" style="min-width: 100%">
<tbody>
<tr>
<td class="mcnImageContent" valign="top" style="padding-right: 9px; padding-left: 9px; padding-top: 0; padding-bottom: 0; text-align: center;">
<a style="text-decoration: none" href="http://afmda.org"><img align="center" alt="American Friends of Magen David Adom" src="https://secure2.convio.net/afmda/images/content/pagebuilder/logo-bb.png" width="196" style="max-width: 196px; padding-bottom: 0; display: inline !important; vertical-align: bottom;" class="mcnImage"></a>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td valign="top" id="templateUpperBody">
<table border="0" cellpadding="0" cellspacing="0" width="100%" class="mcnTextBlock" style="min-width: 100%">
<tbody class="mcnTextBlockOuter">
<tr>
<td valign="top" class="mcnTextBlockInner" style="padding-top: 9px">
<table align="left" border="0" cellpadding="0" cellspacing="0" style="max-width: 100%; min-width: 100%" width="100%" class="mcnTextContentContainer">
<tbody>
<tr>
<td valign="top" class="mcnTextContent" style="padding-top: 0; padding-right: 18px; padding-bottom: 9px; padding-left: 18px;">
<div style="text-align: center"><span style="font-family: open sans, helvetica neue, helvetica, arial, sans-serif;"><span style="font-size: 16px">A generous contribution has been made to Magen David
Adom</span><br><br><span style="font-size: 16px">in honor of</span><br><br><span style="font-size: 18px"><em><span class="ecardTitle"></span> <span class="ecardFirstName"></span> <span
class="ecardLastName"></span></em></span></span></div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
<table border="0" cellpadding="0" cellspacing="0" width="100%" class="mcnDividerBlock" style="min-width: 100%">
<tbody class="mcnDividerBlockOuter">
<tr>
<td class="mcnDividerBlockInner" style="min-width: 100%; padding: 18px">
<table class="mcnDividerContent" border="0" cellpadding="0" cellspacing="0" width="100%" style="min-width: 100%; border-top: 2px solid #eaeaea">
<tbody>
<tr>
<td><span></span></td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td valign="top" id="templateColumns">
<table align="left" border="0" cellpadding="0" cellspacing="0" width="300" class="columnWrapper">
<tbody>
<tr>
<td valign="top" class="columnContainer">
<table border="0" cellpadding="0" cellspacing="0" width="100%" class="mcnTextBlock" style="min-width: 100%">
<tbody class="mcnTextBlockOuter">
<tr>
<td valign="top" class="mcnTextBlockInner" style="padding-top: 9px">
<table align="left" border="0" cellpadding="0" cellspacing="0" style="max-width: 100%; min-width: 100%" width="100%" class="mcnTextContentContainer">
<tbody>
<tr>
<td valign="top" class="mcnTextContent" style="padding-top: 0; padding-right: 18px; padding-bottom: 9px; padding-left: 18px;">
<div style="text-align: left"><em>Message:</em><br><br>
<p class="ecardMessage"></p>
</div>
<div style="text-align: center"><br><br><br></div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
<table align="left" border="0" cellpadding="0" cellspacing="0" width="300" class="columnWrapper">
<tbody>
<tr>
<td valign="top" class="columnContainer">
<table border="0" cellpadding="0" cellspacing="0" width="100%" class="mcnImageCardBlock">
<tbody class="mcnImageCardBlockOuter">
<tr>
<td class="mcnImageCardBlockInner" valign="top" style="padding-top: 9px; padding-right: 18px; padding-bottom: 9px; padding-left: 18px;">
<table align="right" border="0" cellpadding="0" cellspacing="0" class="mcnImageCardBottomContent" width="100%" style="background-color: #404040">
<tbody>
<tr>
<td class="mcnImageCardBottomImageContent" align="left" valign="top" style="padding-top: 0px; padding-right: 0px; padding-bottom: 0; padding-left: 0px;"><img alt=""
src="http://secure.afmda.org/images/content/pagebuilder/afmda-tribute-cards-2020-IH-ambulance-360px.jpg" width="264" style="max-width: 360px" class="mcnImage"></td>
</tr>
<tr>
<td class="mcnTextContent" valign="top" style="padding: 9px 18px; color: #f2f2f2; font-family: Helvetica; font-size: 14px; font-weight: normal; text-align: center;" width="246"><span
style="font-size: 12px">Magen David Adom is Israel's national paramedic and Red Cross service, protecting the health and lives of Israel's 9.3 million people.</span></td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</div>
<div id="getWellEcardPreviewContainer" style="display: none;">
<table id="bodyTable">
<tbody>
<tr>
<td id="bodyCell">
<table class="templateContainer">
<tbody>
<tr>
<td valign="top" id="templateHeader">
<table class="mcnImageBlock" style="min-width: 100%">
<tbody class="mcnImageBlockOuter">
<tr>
<td style="padding: 9px" class="mcnImageBlockInner">
<table class="mcnImageContentContainer" style="min-width: 100%">
<tbody>
<tr>
<td class="mcnImageContent" style="padding-right: 9px; padding-left: 9px; padding-top: 0; padding-bottom: 0; text-align: center">
<a style="text-decoration: none" href="http://afmda.org"><img alt="American Friends of Magen David Adom" src="https://secure2.convio.net/afmda/images/content/pagebuilder/logo-bb.png" width="196" style="max-width: 196px; padding-bottom: 0; display: inline !important; vertical-align: bottom;" class="mcnImage"></a>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td valign="top" id="templateUpperBody">
<table class="mcnTextBlock" style="min-width: 100%">
<tbody class="mcnTextBlockOuter">
<tr>
<td class="mcnTextBlockInner" style="padding-top: 9px">
<table style="max-width: 100%; min-width: 100%" class="mcnTextContentContainer">
<tbody>
<tr>
<td class="mcnTextContent" style="padding-top: 0; padding-right: 18px; padding-bottom: 9px; padding-left: 18px;"><img
src="http://secure.afmda.org/images/content/pagebuilder/afmda-tribute-cards-2020-Other-600px.jpg"><br><br>
<div style="text-align: center"><span style="font-family: open sans, helvetica neue, helvetica, arial, sans-serif; font-size: 16px;">A generous contribution has been made to Magen David Adom.</span><br></div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
<table class="mcnDividerBlock" style="min-width: 100%">
<tbody class="mcnDividerBlockOuter">
<tr>
<td class="mcnDividerBlockInner" style="min-width: 100%; padding: 18px">
<table class="mcnDividerContent" width="100%" style="min-width: 100%; border-top: 2px solid #eaeaea">
<tbody>
<tr>
<td><span></span></td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td valign="top" id="templateColumns">
<table class="columnWrapper">
<tbody>
<tr>
<td valign="top" class="columnContainer">
<table class="mcnTextBlock" style="min-width: 100%">
<tbody class="mcnTextBlockOuter">
<tr>
<td class="mcnTextBlockInner" style="padding-top: 9px">
<table style="max-width: 100%; min-width: 100%" class="mcnTextContentContainer">
<tbody>
<tr>
<td valign="top" class="mcnTextContent" style="padding-top: 0; padding-right: 18px; padding-bottom: 9px; padding-left: 18px;">
<div style="text-align: left"><em>Message:</em><br><br>
<p class="ecardMessage"></p>
</div>
<div style="text-align: center"><br><br><br></div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</div>
<div id="inMomoryEcardPreviewContainer" style="display: none;">
<table id="bodyTable">
<tbody>
<tr>
<td id="bodyCell">
<table class="templateContainer">
<tbody>
<tr>
<td id="templateHeader">
<table>
<tbody class="mcnImageBlockOuter">
<tr>
<td style="padding: 9px" class="mcnImageBlockInner">
<table class="mcnImageContentContainer">
<tbody>
<tr>
<td class="mcnImageContent" style="padding-right: 9px; padding-left: 9px; padding-top: 0; padding-bottom: 0; text-align: center;">
<a style="text-decoration: none" href="http://afmda.org"><img alt="American Friends of Magen David Adom" src="https://secure2.convio.net/afmda/images/content/pagebuilder/logo-bb.png" width="196" style="max-width: 196px; padding-bottom: 0; display: inline !important; vertical-align: bottom;" class="mcnImage"></a>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td valign="top" id="templateUpperBody">
<table width="100%" class="mcnTextBlock" style="min-width: 100%">
<tbody class="mcnTextBlockOuter">
<tr>
<td valign="top" class="mcnTextBlockInner" style="padding-top: 9px">
<table style="max-width: 100%; min-width: 100%" width="100%" class="mcnTextContentContainer">
<tbody>
<tr>
<td valign="top" class="mcnTextContent" style="padding-top: 0; padding-right: 18px; padding-bottom: 9px; padding-left: 18px;">
<div style="text-align: center"><img class="banner-img" src="http://secure.afmda.org/images/content/pagebuilder/afmda-tribute-cards-2020-IM-WeRemember.jpg" alt="We Remember."><br><br><span
style="font-family: open sans, helvetica neue, helvetica, arial, sans-serif; font-size: 16px;">A generous contribution has been made to Magen David Adom</span><br><br><span
style="font-family: open sans, helvetica neue, helvetica, arial, sans-serif; font-size: 16px;">in memory of</span><br><br><span
style="font-family: open sans, helvetica neue, helvetica, arial, sans-serif; font-size: 18px;"><em><span class="ecardTitle"></span> <span class="ecardFirstName"></span> <span
class="ecardLastName"></span></em></span></div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
<table width="100%" class="mcnDividerBlock" style="min-width: 100%">
<tbody class="mcnDividerBlockOuter">
<tr>
<td class="mcnDividerBlockInner" style="min-width: 100%; padding: 18px">
<table class="mcnDividerContent" width="100%" style="min-width: 100%; border-top: 2px solid #eaeaea">
<tbody>
<tr>
<td><span></span></td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td valign="top" id="templateColumns">
<table width="300" class="columnWrapper">
<tbody>
<tr>
<td valign="top" class="columnContainer">
<table width="100%" class="mcnTextBlock" style="min-width: 100%">
<tbody class="mcnTextBlockOuter">
<tr>
<td valign="top" class="mcnTextBlockInner" style="padding-top: 9px">
<table style="max-width: 100%; min-width: 100%" width="100%" class="mcnTextContentContainer">
<tbody>
<tr>
<td valign="top" class="mcnTextContent" style=" padding-top: 0; padding-right: 18px; padding-bottom: 9px; padding-left: 18px;">
<div style="text-align: left"><em>Message:</em><br><br>
<p class="ecardMessage"></p>
</div>
<div style="text-align: center"><br><br><br></div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</div>
<div id="tribute_notify_recip_name_row" class="form-row form-text TribMailFields" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_notify_recip_namename">Notification Recipient Name</label>
<input type="text" name="tribute_notify_recip_namename" id="tribute_notify_recip_namename" value="" maxlength="70">
<input type="hidden" name="tribute_notify_recip_namesubmit_skip" id="tribute_notify_recip_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_name_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_name'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_street1_row" class="form-row form-text TribMailFields" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_notify_recip_street1name">Notification Recipient Street 1</label>
<input type="text" name="tribute_notify_recip_street1name" id="tribute_notify_recip_street1name" value="" maxlength="50">
<input type="hidden" name="tribute_notify_recip_street1submit_skip" id="tribute_notify_recip_street1submit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_street1', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_street1_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_street1'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_street2_row" class="form-row form-text TribMailFields" style="display: none;">
<div class="form-content">
<label for="tribute_notify_recip_street2name">Notification Recipient Street 2</label>
<input type="text" name="tribute_notify_recip_street2name" id="tribute_notify_recip_street2name" value="" maxlength="50">
<input type="hidden" name="tribute_notify_recip_street2submit_skip" id="tribute_notify_recip_street2submit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_street2', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_street2_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_street2'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_city_row" class="form-row form-text TribMailFields" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_notify_recip_cityname">Notification Recipient City</label>
<input type="text" name="tribute_notify_recip_cityname" id="tribute_notify_recip_cityname" value="" maxlength="50">
<input type="hidden" name="tribute_notify_recip_citysubmit_skip" id="tribute_notify_recip_citysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_city', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_city_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_city'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_state_row" class="form-row form-selectlist TribMailFields" style="display: none;">
<div class="form-content">
<label class="FormLabel" for="tribute_notify_recip_state"><span class="field-required"></span> Notification Recipient State/Province</label>
<select name="tribute_notify_recip_state" id="tribute_notify_recip_state" size="1" onchange="fire_obs_comp_event('tribute_notify_recip_state', this)" readonly="readonly" onfocus="this.removeAttribute('readonly');">
<option></option>
<option value="AK">AK - Alaska</option>
<option value="AL">AL - Alabama</option>
<option value="AR">AR - Arkansas</option>
<option value="AZ">AZ - Arizona</option>
<option value="CA">CA - California</option>
<option value="CO">CO - Colorado</option>
<option value="CT">CT - Connecticut</option>
<option value="DC">DC - District of Columbia</option>
<option value="DE">DE - Delaware</option>
<option value="FL">FL - Florida</option>
<option value="GA">GA - Georgia</option>
<option value="HI">HI - Hawaii</option>
<option value="IA">IA - Iowa</option>
<option value="ID">ID - Idaho</option>
<option value="IL">IL - Illinois</option>
<option value="IN">IN - Indiana</option>
<option value="KS">KS - Kansas</option>
<option value="KY">KY - Kentucky</option>
<option value="LA">LA - Louisiana</option>
<option value="MA">MA - Massachusetts</option>
<option value="MD">MD - Maryland</option>
<option value="ME">ME - Maine</option>
<option value="MI">MI - Michigan</option>
<option value="MN">MN - Minnesota</option>
<option value="MO">MO - Missouri</option>
<option value="MS">MS - Mississippi</option>
<option value="MT">MT - Montana</option>
<option value="NC">NC - North Carolina</option>
<option value="ND">ND - North Dakota</option>
<option value="NE">NE - Nebraska</option>
<option value="NH">NH - New Hampshire</option>
<option value="NJ">NJ - New Jersey</option>
<option value="NM">NM - New Mexico</option>
<option value="NV">NV - Nevada</option>
<option value="NY">NY - New York</option>
<option value="OH">OH - Ohio</option>
<option value="OK">OK - Oklahoma</option>
<option value="OR">OR - Oregon</option>
<option value="PA">PA - Pennsylvania</option>
<option value="RI">RI - Rhode Island</option>
<option value="SC">SC - South Carolina</option>
<option value="SD">SD - South Dakota</option>
<option value="TN">TN - Tennessee</option>
<option value="TX">TX - Texas</option>
<option value="UT">UT - Utah</option>
<option value="VA">VA - Virginia</option>
<option value="VT">VT - Vermont</option>
<option value="WA">WA - Washington</option>
<option value="WI">WI - Wisconsin</option>
<option value="WV">WV - West Virginia</option>
<option value="WY">WY - Wyoming</option>
<option value="AS">AS - American Samoa</option>
<option value="FM">FM - Federated States of Micronesia</option>
<option value="GU">GU - Guam</option>
<option value="MH">MH - Marshall Islands</option>
<option value="MP">MP - Northern Mariana Islands</option>
<option value="PR">PR - Puerto Rico</option>
<option value="PW">PW - Palau</option>
<option value="VI">VI - Virgin Islands</option>
<option value="AA">AA - Armed Forces Americas</option>
<option value="AE">AE - Armed Forces</option>
<option value="AP">AP - Armed Forces Pacific</option>
<option value="AB">AB - Alberta</option>
<option value="BC">BC - British Columbia</option>
<option value="MB">MB - Manitoba</option>
<option value="NB">NB - New Brunswick</option>
<option value="NL">NL - Newfoundland and Labrador</option>
<option value="NS">NS - Nova Scotia</option>
<option value="NT">NT - Northwest Territories</option>
<option value="NU">NU - Nunavut</option>
<option value="ON">ON - Ontario</option>
<option value="PE">PE - Prince Edward Island</option>
<option value="QC">QC - Quebec</option>
<option value="SK">SK - Saskatchewan</option>
<option value="YT">YT - Yukon</option>
<option value="None">None</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('tribute_notify_recip_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_state_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="tribute_notify_recip_statesubmit_skip" id="tribute_notify_recip_statesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_state_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_state'));
function tribute_notify_recip_state_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('tribute_notify_recip_state', src);
}
}
var el = document.getElementById('tribute_notify_recip_state');
if (el) {
Utils.addEvent(el, 'change', tribute_notify_recip_state_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_zip_row" class="form-row form-text TribMailFields" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_notify_recip_zipname">Notification Recipient ZIP/Postal Code</label>
<input type="text" name="tribute_notify_recip_zipname" id="tribute_notify_recip_zipname" value="" maxlength="50" readonly="readonly" onfocus="this.removeAttribute('readonly');">
<input type="hidden" name="tribute_notify_recip_zipsubmit_skip" id="tribute_notify_recip_zipsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_zip', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_zip_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_zip'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_country_row" class="form-row form-selectlist TribMailFields" style="display: none;">
<div class="form-content">
<label class="FormLabel" for="tribute_notify_recip_country">Notification Recipient Country</label>
<select name="tribute_notify_recip_country" id="tribute_notify_recip_country" size="1" onchange="fire_obs_comp_event('tribute_notify_recip_country', this)" readonly="readonly" onfocus="this.removeAttribute('readonly');">
<option></option>
<option selected="selected" value="United States">United States</option>
<option value="Afghanistan">Afghanistan</option>
<option value="Aland Islands">Aland Islands</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antarctica">Antarctica</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivarian Republic of Venezuela">Bolivarian Republic of Venezuela</option>
<option value="Bonaire, Sint Eustatios and Saba">Bonaire, Sint Eustatios and Saba</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet Island">Bouvet Island</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
<option value="Brunei Darussalam">Brunei Darussalam</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cape Verde">Cape Verde</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Cote D'Ivoire">Cote D'Ivoire</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Curacao">Curacao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</option>
<option value="Democratic People's Republic of Korea">Democratic People's Republic of Korea</option>
<option value="The Democratic Republic of the Congo">The Democratic Republic of the Congo</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Falkland Islands (Malvinas)">Falkland Islands (Malvinas)</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Federated States of Micronesia">Federated States of Micronesia</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="The Former Yugoslav Republic of Macedonia">The Former Yugoslav Republic of Macedonia</option>
<option value="France">France</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern Territories">French Southern Territories</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guernsey">Guernsey</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option>
<option value="Holy See (Vatican City State)">Holy See (Vatican City State)</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Islamic Republic of Iran">Islamic Republic of Iran</option>
<option value="Isle of Man">Isle of Man</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jersey">Jersey</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macao">Macao</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montenegro">Montenegro</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestinian Territory, Occupied">Palestinian Territory, Occupied</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Pitcairn">Pitcairn</option>
<option value="Plurinational State of Bolivia">Plurinational State of Bolivia</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Republic of Korea">Republic of Korea</option>
<option value="Republic of Moldova">Republic of Moldova</option>
<option value="Reunion">Reunion</option>
<option value="Romania">Romania</option>
<option value="Russian Federation">Russian Federation</option>
<option value="Rwanda">Rwanda</option>
<option value="Saint Barthelemy">Saint Barthelemy</option>
<option value="Saint Helena, Ascension and Tristan da Cunha">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Martin (French)">Saint Martin (French)</option>
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia">Serbia</option>
<option value="Seychelles">Seychelles</option>
<option value="S. Georgia & S. Sandwich Isls.">S. Georgia & S. Sandwich Isls.</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Sint Maarten (Dutch)">Sint Maarten (Dutch)</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="South Sudan">South Sudan</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
<option value="Swaziland">Swaziland</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syrian Arab Republic">Syrian Arab Republic</option>
<option value="Taiwan, Province of China">Taiwan, Province of China</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Thailand">Thailand</option>
<option value="Timor-Leste">Timor-Leste</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkey">Turkey</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="United Republic of Tanzania">United Republic of Tanzania</option>
<option value="Uruguay">Uruguay</option>
<option value="USA Minor Outlying Islands">USA Minor Outlying Islands</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Viet Nam">Viet Nam</option>
<option value="Virgin Islands (British)">Virgin Islands (British)</option>
<option value="Virgin Islands (USA)">Virgin Islands (USA)</option>
<option value="Wallis and Futuna">Wallis and Futuna</option>
<option value="Western Sahara">Western Sahara</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('tribute_notify_recip_country', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_country_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="tribute_notify_recip_countrysubmit_skip" id="tribute_notify_recip_countrysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_country', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_country_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_country'));
function tribute_notify_recip_country_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('tribute_notify_recip_country', src);
}
}
var el = document.getElementById('tribute_notify_recip_country');
if (el) {
Utils.addEvent(el, 'change', tribute_notify_recip_country_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<h2 class="section-header-container"> Payment Details </h2>
<div class="row billing_information">
<div id="billing_title_row" class="form-row form-selectlist">
<div class="form-content">
<label class="FormLabel" for="billing_title">Title</label>
<select name="billing_title" id="billing_title" size="1">
<option></option>
<option value="Mr.">Mr.</option>
<option value="Ms.">Ms.</option>
<option value="Mrs.">Mrs.</option>
<option value="Miss">Miss</option>
<option value="Dr.">Dr.</option>
<option value="Mx.">Mx.</option>
<option value="Rabbi">Rabbi</option>
<option value="Rev.">Rev.</option>
<option value="Pastor">Pastor</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('billing_title', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_title_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="billing_titlesubmit" id="billing_titlesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_title', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_title_row', _display);
this.disable_submit_flag(_hidden);
}
function billing_title_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_title', src);
}
}
var el = document.getElementById('billing_title');
if (el) {
Utils.addEvent(el, 'change', billing_title_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<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">Card Holder First Name</label>
<input type="text" name="billing_first_namename" id="billing_first_namename" value="" maxlength="50">
<input type="hidden" name="billing_first_namesubmit" id="billing_first_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_first_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_first_name_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_middle_name_row" class="form-row form-text">
<div class="form-content">
<label for="billing_middle_namename">Middle Initial</label>
<input type="text" name="billing_middle_namename" id="billing_middle_namename" value="" maxlength="50">
<input type="hidden" name="billing_middle_namesubmit" id="billing_middle_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_middle_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_middle_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">Card Holder Last Name</label>
<input type="text" name="billing_last_namename" id="billing_last_namename" value="" maxlength="50">
<input type="hidden" name="billing_last_namesubmit" id="billing_last_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_last_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_last_name_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
</div>
<div class="row billing_information">
<div id="donor_phone_type_row" class="form-row form-selectlist">
<div class="form-content">
<span class="field-required"></span>
<label class="FormLabel" for="donor_phone_type">Phone Type</label>
<select name="donor_phone_type" id="donor_phone_type" size="1">
<option value="home_phone">Phone</option>
<option value="work_phone">Work Phone</option>
<option value="mobile_phone">Mobile Phone</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('donor_phone_type', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_phone_type_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="donor_phone_typesubmit" id="donor_phone_typesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_phone_type', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_phone_type_row', _display);
this.disable_submit_flag(_hidden);
}
function donor_phone_type_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('donor_phone_type', src);
}
}
var el = document.getElementById('donor_phone_type');
if (el) {
Utils.addEvent(el, 'change', donor_phone_type_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="donor_phone_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="donor_phonename">Phone Number</label>
<input type="text" name="donor_phonename" id="donor_phonename" value="" maxlength="50">
<input type="hidden" name="donor_phonesubmit" id="donor_phonesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_phone', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_phone_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
</div>
<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">
<input type="hidden" name="donor_email_addresssubmit" id="donor_email_addresssubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_email_address', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_email_address_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div class="row billing_information">
<div id="billing_addr_street1_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_addr_street1name">Address</label>
<input type="text" name="billing_addr_street1name" id="billing_addr_street1name" value="" maxlength="50">
<input type="hidden" name="billing_addr_street1submit" id="billing_addr_street1submit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_street1', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_street1_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_street2_row" class="form-row form-text">
<div class="form-content">
<label for="billing_addr_street2name">Address 2</label>
<input type="text" name="billing_addr_street2name" id="billing_addr_street2name" value="" maxlength="50">
<input type="hidden" name="billing_addr_street2submit" id="billing_addr_street2submit" value="true">
<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>
<div class="row billing_information">
<div id="billing_addr_city_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_addr_cityname">City</label>
<input type="text" name="billing_addr_cityname" id="billing_addr_cityname" value="" maxlength="50">
<input type="hidden" name="billing_addr_citysubmit" id="billing_addr_citysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_city', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_city_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_state_row" class="form-row form-selectlist">
<div class="form-content">
<span class="field-required"></span>
<label class="FormLabel" for="billing_addr_state">State</label>
<select name="billing_addr_state" id="billing_addr_state" size="1" onchange="fire_obs_comp_event('billing_addr_state', this)">
<option></option>
<option value="AK">AK - Alaska</option>
<option value="AL">AL - Alabama</option>
<option value="AR">AR - Arkansas</option>
<option value="AZ">AZ - Arizona</option>
<option value="CA">CA - California</option>
<option value="CO">CO - Colorado</option>
<option value="CT">CT - Connecticut</option>
<option value="DC">DC - District of Columbia</option>
<option value="DE">DE - Delaware</option>
<option value="FL">FL - Florida</option>
<option value="GA">GA - Georgia</option>
<option value="HI">HI - Hawaii</option>
<option value="IA">IA - Iowa</option>
<option value="ID">ID - Idaho</option>
<option value="IL">IL - Illinois</option>
<option value="IN">IN - Indiana</option>
<option value="KS">KS - Kansas</option>
<option value="KY">KY - Kentucky</option>
<option value="LA">LA - Louisiana</option>
<option value="MA">MA - Massachusetts</option>
<option value="MD">MD - Maryland</option>
<option value="ME">ME - Maine</option>
<option value="MI">MI - Michigan</option>
<option value="MN">MN - Minnesota</option>
<option value="MO">MO - Missouri</option>
<option value="MS">MS - Mississippi</option>
<option value="MT">MT - Montana</option>
<option value="NC">NC - North Carolina</option>
<option value="ND">ND - North Dakota</option>
<option value="NE">NE - Nebraska</option>
<option value="NH">NH - New Hampshire</option>
<option value="NJ">NJ - New Jersey</option>
<option value="NM">NM - New Mexico</option>
<option value="NV">NV - Nevada</option>
<option value="NY">NY - New York</option>
<option value="OH">OH - Ohio</option>
<option value="OK">OK - Oklahoma</option>
<option value="OR">OR - Oregon</option>
<option value="PA">PA - Pennsylvania</option>
<option value="RI">RI - Rhode Island</option>
<option value="SC">SC - South Carolina</option>
<option value="SD">SD - South Dakota</option>
<option value="TN">TN - Tennessee</option>
<option value="TX">TX - Texas</option>
<option value="UT">UT - Utah</option>
<option value="VA">VA - Virginia</option>
<option value="VT">VT - Vermont</option>
<option value="WA">WA - Washington</option>
<option value="WI">WI - Wisconsin</option>
<option value="WV">WV - West Virginia</option>
<option value="WY">WY - Wyoming</option>
<option value="AS">AS - American Samoa</option>
<option value="FM">FM - Federated States of Micronesia</option>
<option value="GU">GU - Guam</option>
<option value="MH">MH - Marshall Islands</option>
<option value="MP">MP - Northern Mariana Islands</option>
<option value="PR">PR - Puerto Rico</option>
<option value="PW">PW - Palau</option>
<option value="VI">VI - Virgin Islands</option>
<option value="AA">AA - Armed Forces Americas</option>
<option value="AE">AE - Armed Forces</option>
<option value="AP">AP - Armed Forces Pacific</option>
<option value="AB">AB - Alberta</option>
<option value="BC">BC - British Columbia</option>
<option value="MB">MB - Manitoba</option>
<option value="NB">NB - New Brunswick</option>
<option value="NL">NL - Newfoundland and Labrador</option>
<option value="NS">NS - Nova Scotia</option>
<option value="NT">NT - Northwest Territories</option>
<option value="NU">NU - Nunavut</option>
<option value="ON">ON - Ontario</option>
<option value="PE">PE - Prince Edward Island</option>
<option value="QC">QC - Quebec</option>
<option value="SK">SK - Saskatchewan</option>
<option value="YT">YT - Yukon</option>
<option value="None">None</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('billing_addr_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_state_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="billing_addr_statesubmit" id="billing_addr_statesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_state_row', _display);
this.disable_submit_flag(_hidden);
}
function billing_addr_state_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('billing_addr_state', src);
}
}
var el = document.getElementById('billing_addr_state');
if (el) {
Utils.addEvent(el, 'change', billing_addr_state_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_zip_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_addr_zipname">ZIP Code</label>
<input type="text" name="billing_addr_zipname" id="billing_addr_zipname" value="" maxlength="50">
<input type="hidden" name="billing_addr_zipsubmit" id="billing_addr_zipsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_zip', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_zip_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
</div>
<div id="billing_addr_country_row" class="form-row form-selectlist">
<div class="form-content">
<span class="field-required"></span>
<label class="FormLabel" for="billing_addr_country">Country</label>
<select name="billing_addr_country" id="billing_addr_country" size="1" onchange="fire_obs_comp_event('billing_addr_country', this)">
<option></option>
<option selected="selected" value="United States">United States</option>
<option value="Afghanistan">Afghanistan</option>
<option value="Aland Islands">Aland Islands</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antarctica">Antarctica</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivarian Republic of Venezuela">Bolivarian Republic of Venezuela</option>
<option value="Bonaire, Sint Eustatios and Saba">Bonaire, Sint Eustatios and Saba</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet Island">Bouvet Island</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
<option value="Brunei Darussalam">Brunei Darussalam</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cape Verde">Cape Verde</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Cote D'Ivoire">Cote D'Ivoire</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Curacao">Curacao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</option>
<option value="Democratic People's Republic of Korea">Democratic People's Republic of Korea</option>
<option value="The Democratic Republic of the Congo">The Democratic Republic of the Congo</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Falkland Islands (Malvinas)">Falkland Islands (Malvinas)</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Federated States of Micronesia">Federated States of Micronesia</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="The Former Yugoslav Republic of Macedonia">The Former Yugoslav Republic of Macedonia</option>
<option value="France">France</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern Territories">French Southern Territories</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guernsey">Guernsey</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option>
<option value="Holy See (Vatican City State)">Holy See (Vatican City State)</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Islamic Republic of Iran">Islamic Republic of Iran</option>
<option value="Isle of Man">Isle of Man</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jersey">Jersey</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macao">Macao</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montenegro">Montenegro</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestinian Territory, Occupied">Palestinian Territory, Occupied</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Pitcairn">Pitcairn</option>
<option value="Plurinational State of Bolivia">Plurinational State of Bolivia</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Republic of Korea">Republic of Korea</option>
<option value="Republic of Moldova">Republic of Moldova</option>
<option value="Reunion">Reunion</option>
<option value="Romania">Romania</option>
<option value="Russian Federation">Russian Federation</option>
<option value="Rwanda">Rwanda</option>
<option value="Saint Barthelemy">Saint Barthelemy</option>
<option value="Saint Helena, Ascension and Tristan da Cunha">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Martin (French)">Saint Martin (French)</option>
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia">Serbia</option>
<option value="Seychelles">Seychelles</option>
<option value="S. Georgia & S. Sandwich Isls.">S. Georgia & S. Sandwich Isls.</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Sint Maarten (Dutch)">Sint Maarten (Dutch)</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="South Sudan">South Sudan</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
<option value="Swaziland">Swaziland</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syrian Arab Republic">Syrian Arab Republic</option>
<option value="Taiwan, Province of China">Taiwan, Province of China</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Thailand">Thailand</option>
<option value="Timor-Leste">Timor-Leste</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkey">Turkey</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="United Republic of Tanzania">United Republic of Tanzania</option>
<option value="Uruguay">Uruguay</option>
<option value="USA Minor Outlying Islands">USA Minor Outlying Islands</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Viet Nam">Viet Nam</option>
<option value="Virgin Islands (British)">Virgin Islands (British)</option>
<option value="Virgin Islands (USA)">Virgin Islands (USA)</option>
<option value="Wallis and Futuna">Wallis and Futuna</option>
<option value="Western Sahara">Western Sahara</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('billing_addr_country', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_country_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="billing_addr_countrysubmit" id="billing_addr_countrysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_country', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_country_row', _display);
this.disable_submit_flag(_hidden);
}
function billing_addr_country_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('billing_addr_country', src);
}
}
var el = document.getElementById('billing_addr_country');
if (el) {
Utils.addEvent(el, 'change', billing_addr_country_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div 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);"><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>
<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);"><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">
<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">
<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">
<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)">
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8">08</option>
<option value="9">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12" selected="selected">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)">
<option value="2023" selected="selected">2023</option>
<option value="2024">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
<option value="2027">2027</option>
<option value="2028">2028</option>
<option value="2029">2029</option>
<option value="2030">2030</option>
<option value="2031">2031</option>
<option value="2032">2032</option>
<option value="2033">2033</option>
</select>
</fieldset>
<input type="hidden" name="responsive_payment_typecc_exp_date_DAY" id="responsive_payment_typecc_exp_date_DAY" value="1">
<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">
<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=afmda&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="cc-csc">
<input type="hidden" name="responsive_payment_typecc_cvvsubmit" id="responsive_payment_typecc_cvvsubmit" value="true">
<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_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">
<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>
<h2 class="section-header-container"> Your Information </h2>
<div class="form-row form-checkbox" id="different_donor_information_row"><input type="checkbox" id="different_donor_information" name="different_donor_information"><label for="different_donor_information">Click here if donor information is
different than billing information.</label></div>
<div class="custom-field-container form-row REorgGiftStatusParentContainer">
<div class="form-content">
<div class="form-input-label-block">
<label for="re_orggiftstatus_dropdown">RE_OrgGiftStatus</label>
</div>
<fieldset>
<input type="checkbox" name="re_orggiftstatus_radio" id="re_orggiftstatus_radio" value="true">
<label class="custom-element-checkbox-label" for="re_orggiftstatus_radio">Make this gift on behalf of an organization</label>
</fieldset>
<input type="hidden" name="re_orggiftstatussubmit" id="re_orggiftstatussubmit" value="true">
</div>
</div>
<div class="donor_information_section">
<div class="row billing_information donor_information">
<div id="donor_title_row" class="form-row form-selectlist hideInformation">
<div class="form-content">
<label class="FormLabel" for="donor_title">Donor Title</label>
<select name="donor_title" id="donor_title" size="1">
<option></option>
<option value="Mr.">Mr.</option>
<option value="Ms.">Ms.</option>
<option value="Mrs.">Mrs.</option>
<option value="Miss">Miss</option>
<option value="Dr.">Dr.</option>
<option value="Mx.">Mx.</option>
<option value="Rabbi">Rabbi</option>
<option value="Rev.">Rev.</option>
<option value="Pastor">Pastor</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('donor_title', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_title_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="donor_titlesubmit" id="donor_titlesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_title', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_title_row', _display);
this.disable_submit_flag(_hidden);
}
function donor_title_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('donor_title', src);
}
}
var el = document.getElementById('donor_title');
if (el) {
Utils.addEvent(el, 'change', donor_title_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="donor_first_name_row" class="form-row form-text hideInformation">
<div class="form-content">
<span class="field-required"></span>
<label for="donor_first_namename">Donor First Name</label>
<input type="text" name="donor_first_namename" id="donor_first_namename" value="" maxlength="50">
<input type="hidden" name="donor_first_namesubmit" id="donor_first_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_first_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_first_name_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="donor_middle_name_row" class="form-row form-text hideInformation" style="display: inline-block;">
<div class="form-content">
<label for="donor_middle_namename">Middle Initial</label>
<input type="text" name="donor_middle_namename" id="donor_middle_namename" value="" maxlength="50">
<input type="hidden" name="donor_middle_namesubmit" id="donor_middle_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_middle_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_middle_name_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="donor_last_name_row" class="form-row form-text hideInformation" style="display: inline-block;">
<div class="form-content">
<span class="field-required"></span>
<label for="donor_last_namename">Donor Last Name</label>
<input type="text" name="donor_last_namename" id="donor_last_namename" value="" maxlength="50">
<input type="hidden" name="donor_last_namesubmit" id="donor_last_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_last_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_last_name_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
</div>
<div class="row donor_information">
<div class="custom-field-container form-row orgContactParentContainer" style="display: none;">
<div class="form-content">
<div class="form-input-label-block">
<label for="re_orgcontactfirstname_input"><span class="field-required"></span> Contact First Name</label>
</div>
<input type="text" name="re_orgcontactfirstname_input" id="re_orgcontactfirstname_input" value="" maxlength="255">
<input type="hidden" name="re_orgcontactfirstnamesubmit" id="re_orgcontactfirstnamesubmit" value="true">
</div>
</div>
<div class="custom-field-container form-row orgContactParentContainer" style="display: none;">
<div class="form-content">
<div class="form-input-label-block">
<label for="re_orgcontactlastname_input"><span class="field-required"></span> Contact Last Name</label>
</div>
<input type="text" name="re_orgcontactlastname_input" id="re_orgcontactlastname_input" value="" maxlength="255">
<input type="hidden" name="re_orgcontactlastnamesubmit" id="re_orgcontactlastnamesubmit" value="true">
</div>
</div>
</div>
<div class="row billing_information donor_information">
<div id="donor_addr_street1_row" class="form-row form-text hideInformation">
<div class="form-content">
<span class="field-required"></span>
<label for="donor_addr_street1name">Donor Address</label>
<input type="text" name="donor_addr_street1name" id="donor_addr_street1name" value="" maxlength="50">
<input type="hidden" name="donor_addr_street1submit" id="donor_addr_street1submit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_addr_street1', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_addr_street1_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="donor_addr_street2_row" class="form-row form-text hideInformation">
<div class="form-content">
<label for="donor_addr_street2name">Donor Address 2</label>
<input type="text" name="donor_addr_street2name" id="donor_addr_street2name" value="" maxlength="50">
<input type="hidden" name="donor_addr_street2submit" id="donor_addr_street2submit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_addr_street2', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_addr_street2_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
</div>
<div class="row billing_information donor_information">
<div id="donor_addr_city_row" class="form-row form-text hideInformation">
<div class="form-content">
<span class="field-required"></span>
<label for="donor_addr_cityname">Donor City</label>
<input type="text" name="donor_addr_cityname" id="donor_addr_cityname" value="" maxlength="50">
<input type="hidden" name="donor_addr_citysubmit" id="donor_addr_citysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_addr_city', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_addr_city_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="donor_addr_state_row" class="form-row form-selectlist hideInformation">
<div class="form-content">
<span class="field-required"></span>
<label class="FormLabel" for="donor_addr_state">Donor State</label>
<select name="donor_addr_state" id="donor_addr_state" size="1" onchange="fire_obs_comp_event('donor_addr_state', this)">
<option></option>
<option value="AK">AK - Alaska</option>
<option value="AL">AL - Alabama</option>
<option value="AR">AR - Arkansas</option>
<option value="AZ">AZ - Arizona</option>
<option value="CA">CA - California</option>
<option value="CO">CO - Colorado</option>
<option value="CT">CT - Connecticut</option>
<option value="DC">DC - District of Columbia</option>
<option value="DE">DE - Delaware</option>
<option value="FL">FL - Florida</option>
<option value="GA">GA - Georgia</option>
<option value="HI">HI - Hawaii</option>
<option value="IA">IA - Iowa</option>
<option value="ID">ID - Idaho</option>
<option value="IL">IL - Illinois</option>
<option value="IN">IN - Indiana</option>
<option value="KS">KS - Kansas</option>
<option value="KY">KY - Kentucky</option>
<option value="LA">LA - Louisiana</option>
<option value="MA">MA - Massachusetts</option>
<option value="MD">MD - Maryland</option>
<option value="ME">ME - Maine</option>
<option value="MI">MI - Michigan</option>
<option value="MN">MN - Minnesota</option>
<option value="MO">MO - Missouri</option>
<option value="MS">MS - Mississippi</option>
<option value="MT">MT - Montana</option>
<option value="NC">NC - North Carolina</option>
<option value="ND">ND - North Dakota</option>
<option value="NE">NE - Nebraska</option>
<option value="NH">NH - New Hampshire</option>
<option value="NJ">NJ - New Jersey</option>
<option value="NM">NM - New Mexico</option>
<option value="NV">NV - Nevada</option>
<option value="NY">NY - New York</option>
<option value="OH">OH - Ohio</option>
<option value="OK">OK - Oklahoma</option>
<option value="OR">OR - Oregon</option>
<option value="PA">PA - Pennsylvania</option>
<option value="RI">RI - Rhode Island</option>
<option value="SC">SC - South Carolina</option>
<option value="SD">SD - South Dakota</option>
<option value="TN">TN - Tennessee</option>
<option value="TX">TX - Texas</option>
<option value="UT">UT - Utah</option>
<option value="VA">VA - Virginia</option>
<option value="VT">VT - Vermont</option>
<option value="WA">WA - Washington</option>
<option value="WI">WI - Wisconsin</option>
<option value="WV">WV - West Virginia</option>
<option value="WY">WY - Wyoming</option>
<option value="AS">AS - American Samoa</option>
<option value="FM">FM - Federated States of Micronesia</option>
<option value="GU">GU - Guam</option>
<option value="MH">MH - Marshall Islands</option>
<option value="MP">MP - Northern Mariana Islands</option>
<option value="PR">PR - Puerto Rico</option>
<option value="PW">PW - Palau</option>
<option value="VI">VI - Virgin Islands</option>
<option value="AA">AA - Armed Forces Americas</option>
<option value="AE">AE - Armed Forces</option>
<option value="AP">AP - Armed Forces Pacific</option>
<option value="AB">AB - Alberta</option>
<option value="BC">BC - British Columbia</option>
<option value="MB">MB - Manitoba</option>
<option value="NB">NB - New Brunswick</option>
<option value="NL">NL - Newfoundland and Labrador</option>
<option value="NS">NS - Nova Scotia</option>
<option value="NT">NT - Northwest Territories</option>
<option value="NU">NU - Nunavut</option>
<option value="ON">ON - Ontario</option>
<option value="PE">PE - Prince Edward Island</option>
<option value="QC">QC - Quebec</option>
<option value="SK">SK - Saskatchewan</option>
<option value="YT">YT - Yukon</option>
<option value="None">None</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('donor_addr_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_addr_state_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="donor_addr_statesubmit" id="donor_addr_statesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_addr_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_addr_state_row', _display);
this.disable_submit_flag(_hidden);
}
function donor_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('donor_addr_state', src);
}
}
var el = document.getElementById('donor_addr_state');
if (el) {
Utils.addEvent(el, 'change', donor_addr_state_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="donor_addr_zip_row" class="form-row form-text hideInformation">
<div class="form-content">
<span class="field-required"></span>
<label for="donor_addr_zipname">Donor ZIP Code</label>
<input type="text" name="donor_addr_zipname" id="donor_addr_zipname" value="" maxlength="50">
<input type="hidden" name="donor_addr_zipsubmit" id="donor_addr_zipsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_addr_zip', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_addr_zip_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
</div>
<div class="row donor_information">
<div id="donor_addr_country_row" class="form-row form-selectlist hideInformation">
<div class="form-content">
<span class="field-required"></span>
<label class="FormLabel" for="donor_addr_country">Donor Country</label>
<select name="donor_addr_country" id="donor_addr_country" size="1" onchange="fire_obs_comp_event('donor_addr_country', this)">
<option></option>
<option selected="selected" value="United States">United States</option>
<option value="Afghanistan">Afghanistan</option>
<option value="Aland Islands">Aland Islands</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antarctica">Antarctica</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivarian Republic of Venezuela">Bolivarian Republic of Venezuela</option>
<option value="Bonaire, Sint Eustatios and Saba">Bonaire, Sint Eustatios and Saba</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet Island">Bouvet Island</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
<option value="Brunei Darussalam">Brunei Darussalam</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cape Verde">Cape Verde</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Cote D'Ivoire">Cote D'Ivoire</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Curacao">Curacao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</option>
<option value="Democratic People's Republic of Korea">Democratic People's Republic of Korea</option>
<option value="The Democratic Republic of the Congo">The Democratic Republic of the Congo</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Falkland Islands (Malvinas)">Falkland Islands (Malvinas)</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Federated States of Micronesia">Federated States of Micronesia</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="The Former Yugoslav Republic of Macedonia">The Former Yugoslav Republic of Macedonia</option>
<option value="France">France</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern Territories">French Southern Territories</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guernsey">Guernsey</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option>
<option value="Holy See (Vatican City State)">Holy See (Vatican City State)</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Islamic Republic of Iran">Islamic Republic of Iran</option>
<option value="Isle of Man">Isle of Man</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jersey">Jersey</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macao">Macao</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montenegro">Montenegro</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestinian Territory, Occupied">Palestinian Territory, Occupied</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Pitcairn">Pitcairn</option>
<option value="Plurinational State of Bolivia">Plurinational State of Bolivia</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Republic of Korea">Republic of Korea</option>
<option value="Republic of Moldova">Republic of Moldova</option>
<option value="Reunion">Reunion</option>
<option value="Romania">Romania</option>
<option value="Russian Federation">Russian Federation</option>
<option value="Rwanda">Rwanda</option>
<option value="Saint Barthelemy">Saint Barthelemy</option>
<option value="Saint Helena, Ascension and Tristan da Cunha">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Martin (French)">Saint Martin (French)</option>
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia">Serbia</option>
<option value="Seychelles">Seychelles</option>
<option value="S. Georgia & S. Sandwich Isls.">S. Georgia & S. Sandwich Isls.</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Sint Maarten (Dutch)">Sint Maarten (Dutch)</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="South Sudan">South Sudan</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
<option value="Swaziland">Swaziland</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syrian Arab Republic">Syrian Arab Republic</option>
<option value="Taiwan, Province of China">Taiwan, Province of China</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Thailand">Thailand</option>
<option value="Timor-Leste">Timor-Leste</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkey">Turkey</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="United Republic of Tanzania">United Republic of Tanzania</option>
<option value="Uruguay">Uruguay</option>
<option value="USA Minor Outlying Islands">USA Minor Outlying Islands</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Viet Nam">Viet Nam</option>
<option value="Virgin Islands (British)">Virgin Islands (British)</option>
<option value="Virgin Islands (USA)">Virgin Islands (USA)</option>
<option value="Wallis and Futuna">Wallis and Futuna</option>
<option value="Western Sahara">Western Sahara</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('donor_addr_country', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_addr_country_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="donor_addr_countrysubmit" id="donor_addr_countrysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_addr_country', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_addr_country_row', _display);
this.disable_submit_flag(_hidden);
}
function donor_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('donor_addr_country', src);
}
}
var el = document.getElementById('donor_addr_country');
if (el) {
Utils.addEvent(el, 'change', donor_addr_country_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
</div>
</div>
<div class="custom-field-container form-row ">
<div class="form-content">
<div class="form-input-label-block">
<label for="bequest_info_requested_dropdown">Want to join the MDA Legacy Circle?</label>
</div>
<fieldset>
<input type="checkbox" name="bequest_info_requested_radio" id="bequest_info_requested_radio" value="true">
<label class="custom-element-checkbox-label" for="bequest_info_requested_radio">Yes, send me information about leaving a Legacy to MDA.</label>
</fieldset>
<input type="hidden" name="bequest_info_requestedsubmit" id="bequest_info_requestedsubmit" value="true">
</div>
</div>
<div class="form-row form-checkbox" id="donor_email_opt_in_Row">
<div class="form-content">
<span class="check-box-form-label-text"></span>
<input type="checkbox" name="donor_email_opt_inname" id="donor_email_opt_inname" checked="checked" onclick="fire_obs_comp_event('donor_email_opt_in', this);">
<label for="donor_email_opt_inname"> Yes, I'd like to receive email updates about the work of Magen David Adom. </label>
<script type="text/javascript">
var comp = new ObservableComponent('donor_email_opt_in', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_email_opt_in_Row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('donor_email_opt_inname')) {
document.getElementById('donor_email_opt_inname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('donor_email_opt_inname')) return document.getElementById('donor_email_opt_inname').checked;
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
<input type="hidden" name="donor_email_opt_insubmit" id="donor_email_opt_insubmit" value="true">
</div>
</div>
<div class="form-row form-checkbox" id="donor_postal_opt_in_Row">
<div class="form-content">
<span class="check-box-form-label-text"></span>
<input type="checkbox" name="donor_postal_opt_inname" id="donor_postal_opt_inname" checked="checked" onclick="fire_obs_comp_event('donor_postal_opt_in', this);">
<label for="donor_postal_opt_inname"> Yes, I would like to receive periodic mailings and newsletters about Magen David Adom. </label>
<script type="text/javascript">
var comp = new ObservableComponent('donor_postal_opt_in', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_postal_opt_in_Row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('donor_postal_opt_inname')) {
document.getElementById('donor_postal_opt_inname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('donor_postal_opt_inname')) return document.getElementById('donor_postal_opt_inname').checked;
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
<input type="hidden" name="donor_postal_opt_insubmit" id="donor_postal_opt_insubmit" value="true">
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<div class="custom_optin_message">
<p>American Friends of Magen David Adom collects your personal information to process your donation, issue a tax receipt, and provide updates about our impact and other ways to help. You can unsubscribe or manage your email preferences at
any time.</p>
</div>
</div>
</div>
<div class="button-container clearfix">
<div class="button-sub-container">
<button class="step-button next-step" type="submit" id="pstep_next" name="pstep_next" value="Next">Next</button>
<button class="step-button cancel-step" type="submit" id="pstep_cancel" name="pstep_cancel" value="Cancel" title="Cancel">Cancel</button>
</div>
</div>
<input type="hidden" name="idb" id="idb" value="859315647">
<input type="hidden" name="df_id" id="df_id" value="2000">
<input type="hidden" name="mfc_pref" id="mfc_pref" value="T">
</div>
<input type="hidden" name="2000.donation" id="2000.donation" value="form1">
</div>
<script type="text/javascript">
var submitted = false;
function checkDoubleClick() {
var elCheck = '';
if (elCheck == 'el') {
alert('Form submission is not enabled when previewing an individual data element.');
return false;
} else if (submitted) {
alert('You have already submitted this payment. Please wait....');
return false;
} else {
submitted = true;
return true;
}
}
</script><noscript> </noscript>
</form>Text Content
Toggle navigation MENU SAVING LIVES IS IN OUR BLOOD. AND IT'S IN YOURS TOO. AFMDA is a 501(c)(3) tax-exempt organization. Our federal tax ID number is 13-1790719. All donations are securely protected. * = Required fields DONATION AMOUNT Field Is Required Select an amount $2,500 $1,000 $500 $360 $100 $54 $36 Other Enter amount You have chosen a one-time gift. You could make an even greater impact by giving monthly. I want to make a monthly gift. Yes, I'd like to make an ongoing impact in Israel by becoming a sustaining donor. Please charge the donation amount I've designated to my credit card each month. Learn about how you, your family, synagogue, or community can help provide an urgently needed ambulance and support AFMDA’s Ambulance Emergency Campaign. TRIBUTE CARDS (OPTIONAL) I would like to make this donation in honor or in memory of someone. Honor Gift Type Get Well In Memory of In Honor of Required Honoree Title Mr. Ms. Mrs. Miss Dr. Mx. Rabbi Rev. 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