secure2.wish.org
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Submitted URL: https://click.mail.wish.org/?qs=bf496b918850507a1721cdda5a6c926ed087ac3134dd7d27f893492f73a4936b55a95498c00f39996cbdf0025bbb...
Effective URL: https://secure2.wish.org/site/SPageServer?pagename=donate_today&ft=SPEA&fi=24_85&dest=none&Campaign_ID=MNOO%fy%&Appeal_ID...
Submission: On February 14 via manual from US — Scanned from DE
Effective URL: https://secure2.wish.org/site/SPageServer?pagename=donate_today&ft=SPEA&fi=24_85&dest=none&Campaign_ID=MNOO%fy%&Appeal_ID...
Submission: On February 14 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST https://secure2.wish.org/site/CRDonationAPI;jsessionid=00000000.app20063a?NONCE_TOKEN=D4B2026484049F306BE7587417D87AF8
<form class="donation-form ad-hoc" method="POST" action="https://secure2.wish.org/site/CRDonationAPI;jsessionid=00000000.app20063a?NONCE_TOKEN=D4B2026484049F306BE7587417D87AF8" data-formtype="adhoc" novalidate="novalidate">
<input type="hidden" name="s_chid" value="100-000" data-designation="" class="js--chapter-data-loaded js--chapter-addl-data-loaded">
<input type="hidden" id="ad-hoc__form_type" value="SPEA">
<input type="hidden" id="ad-hoc__form_instance" value="24_85">
<input type="hidden" id="ad-hoc__form_chrome" value="true">
<input type="hidden" name="method" value="donate">
<input type="hidden" name="remember_me" value="false">
<input type="hidden" name="summary" value="data">
<input type="hidden" name="validate" value="true">
<input type="hidden" name="form_id" value="1542">
<input type="hidden" name="processing_fee" value="0">
<input type="hidden" name="original_donation_amount" value="">
<input type="hidden" name="foreign_key1" value="MNOO24">
<input type="hidden" name="foreign_key2" value="UR-100-01">
<input type="hidden" name="foreign_key3" value="24ON-NSP-WNAT">
<input type="hidden" name="foreign_key4" value="OT-NT-APPLFEBSQ4">
<input type="hidden" name="foreign_key5" value="DEV-Multimedia Online">
<input type="hidden" id="s_src" name="s_src" value="mw-email-fr">
<input type="hidden" id="source" name="source" value="mw-email-fr">
<input type="hidden" id="s_subsrc" name="s_subsrc" value="mw-maw14-02-valentines-day-2024-chapter">
<input type="hidden" id="sub_source" name="sub_source" value="mw-maw14-02-valentines-day-2024-chapter">
<input type="hidden" id="presel" name="presel" value="level1">
<input type="hidden" name="currentURL" id="currentURL"
value="https://secure2.wish.org/site/SPageServer?pagename=donate_today&ft=SPEA&fi=24_85&dest=none&Campaign_ID=MNOO%fy%&Appeal_ID=%fy%ON-XXX-APPL&Package_ID=OT-NT-APPLFEBSQ4&Subtype=DEV-Multimedia%20Online&s_src=mw-email-fr&s_subsrc=mw-maw14-02-valentines-day-2024-chapter&level1=75&level2=125&level3=250&mlevel1=20&mlevel2=30&mlevel3=50&presel=level1&utm_campaign=mw-maw14-02-valentines-day-2024-chapter&utm_source=sfmc&utm_medium=email">
<input type="hidden" name="securePath" id="securePath" value="https://secure2.wish.org/site/">
<div class="section-panel section-panel--page-error clearfix hide">
<div class="grid_9 page-error-wrap">
<div class="error-message-danger js--page-error"></div>
</div>
</div>
<div class="donation-step donation-step--1">
<!-- TODO -->
<div class="home-hero-wrap hide--xs">
<div class="home-hero-bg">
<div class="row_12 clearfix">
<div class="home-hero">
<div class="home-hero-banner">
<img src="https://ssl.wish.org/dr_images/img.hero.spex24_85.jpg" alt="Donate Today">
</div>
</div>
</div>
</div>
</div>
<div class="donate-intro">
<h1 id="body_1_h1PageTitle">
<!-- PageBuilder -->
<p>DONATE TODAY</p>
</h1>
<p>
</p>
<p>In honor of American Heart Month, make a gift to help grant wishes for kids with heart conditions and other critical illnesses. <strong>Donate now to provide more kids with the hope and strength of a wish.</strong></p>
<p></p>
</div>
<div class="page-loader js--page-loaded">
<div class="js--page-loader-hidden">
<!--
-->
<div class="section-panel section-panel--donation-levels clearfix" data-defaultamount="$125" data-defaultmonthly="$30">
<div class="grid_9 three">
<h3 class="section-panel__header"> Your Donation </h3>
<div class="row-fluid">
<div class="button-wrap monthly-buttons">
<button type="button" id="js--donate-2onetime" class="active"><span>One-Time Gift</span></button>
<button type="button" id="js--donate-2monthly" class=""><span>Monthly Gift</span></button>
</div>
</div>
<p class="select-amount-text">Select your donation amount:</p>
<div class="row-fluid donation-levels-row">
<!-- Begin Removing Callouts
END Removing Callouts -->
<div class="donation-levels">
<div class="donation-levels-one-time ">
<label class="amounts radio-label-btn selected" for="donation-level-fixed-1">
<input type="radio" name="level_id" data-level="level1" id="donation-level-fixed-1" data-amount="$75" checked="" value="2031"> $75 </label>
<label class="amounts radio-label-btn " for="donation-level-fixed-2">
<input type="radio" name="level_id" data-level="level2" id="donation-level-fixed-2" data-amount="$125" value="2031"> $125 </label>
<label class="amounts radio-label-btn " for="donation-level-fixed-3">
<input type="radio" name="level_id" data-level="level3" id="donation-level-fixed-3" data-amount="$250" value="2031"> $250 </label>
</div>
<div class="donation-levels-monthly hide" data-dm="">
<!--if monthly giving-->
<!--if one time giving form-->
<label class="amounts radio-label-btn " for="donation-mlevel-fixed-1">
<input type="radio" name="level_id" data-level="mlevel1" id="donation-mlevel-fixed-1" data-amount="$20" value="2031"> $20 </label>
<label class="amounts radio-label-btn " for="donation-mlevel-fixed-2">
<input type="radio" name="level_id" data-level="mlevel2" id="donation-mlevel-fixed-2" data-amount="$30" value="2031"> $30 </label>
<label class="amounts radio-label-btn " for="donation-mlevel-fixed-3">
<input type="radio" name="level_id" data-level="mlevel3" id="donation-mlevel-fixed-3" data-amount="$50" value="2031"> $50 </label>
</div>
<label class="other-button radio-label-btn" for="donation-level-other">
<span class="other-amount">
<input type="radio" name="level_id" id="donation-level-other" value="2031">
<input type="text" id="donation-level-other-amount" placeholder="Your best gift" data-minamount="5">
</span>
</label>
</div>
<div class="grid_12">
<div class="donation-levels-error"></div>
</div>
<div class="clearfix mt-m donate-monthly-info hide" style="">
<div class="grid_7">
<!--
calculate one month from today
month + 1 = 3
append the day: 3/14
3
append current year: 3/14/2024
--> Your first donation will be charged today and then monthly starting on 3/14/2024.
</div>
<!--<div class="grid_3 hide">
<a class="js--donate-monthly-learn-more" href="https://secure2.wish.org/site/SPageServer?pagename=donate_today&ft=SPEA&fi=24_85&dest=none&Campaign_ID=MNOO%fy%&Appeal_ID=%fy%ON-XXX-APPL&Package_ID=OT-NT-APPLFEBSQ4&Subtype=DEV-Multimedia%20Online&s_src=mw-email-fr&s_subsrc=mw-maw14-02-valentines-day-2024-chapter&level1=75&level2=125&level3=250&mlevel1=20&mlevel2=30&mlevel3=50&presel=level1&utm_campaign=mw-maw14-02-valentines-day-2024-chapter&utm_source=sfmc&utm_medium=email#">Learn more about our monthly donor program and benefits.</a>
</div>-->
</div>
</div>
<!-- BEGIN: REMOVE MONTHLY OPTION FROM UNDER ASK STRING
END: REMOVE MONTHLY OPTION FROM UNDER ASK STRING -->
</div>
</div>
<div class="section-panel section-panel--donation-options clearfix">
<div class="grid_9 three">
<h3 class="donation-type-header section-panel__header"> Change Donation Type </h3>
<div class="row-fluid mb-m">
<label class="checkbox-label-btn" for="honor-memorial-toggle">
<input type="checkbox" id="honor-memorial-toggle"> Make this an honor / memorial gift </label>
<div class="honor-memorial-product-options pb-s hide" style="">
<h3 class="section-panel__header"> Honor / Memorial Information </h3>
<p> Select your card type and design: </p>
<div class="clearfix honor-memorial-type">
<label class="radio-label-btn selected" for="honor-memorial-tribute-products">
<input type="radio" name="tribute_product_type" id="honor-memorial-tribute-products" value="tribute" checked="" disabled="disabled"> Ecard - In Honor Of </label>
<label class="radio-label-btn " for="honor-memorial-memorial-products">
<input type="radio" name="tribute_product_type" id="honor-memorial-memorial-products" value="memorial" disabled="disabled"> Ecard - Memorial </label>
<label class="radio-label-btn " for="honor-memorial-certificate-products">
<input type="radio" name="tribute_product_type" id="honor-memorial-certificate-products" value="certificate" disabled="disabled"> Printable Certificate </label>
</div>
<div class="honor-memorial-designs honor-memorial-designs--tribute">
<div class="honor-memorial-designs-row clearfix"><label class="" for="honor-memorial-design-HON221_08"><input type="radio" name="product_id" id="honor-memorial-design-HON221_08" value="HON221_08">
<div class="card-wrap"><img src="../Card%20images/General/eCards/HON221-08_250w.jpg"></div><button type="button">Preview</button>
</label><label class="" for="honor-memorial-design-HON21_08"><input type="radio" name="product_id" id="honor-memorial-design-HON21_08" value="HON21_08">
<div class="card-wrap"><img src="../Card%20images/General/eCards/HON21-08_250w.jpg"></div><button type="button">Preview</button>
</label></div>
</div>
<div class="honor-memorial-designs honor-memorial-designs--memorial hide">
<div class="honor-memorial-designs-row clearfix"><label class="" for="honor-memorial-design-MEM21_08"><input type="radio" name="product_id" id="honor-memorial-design-MEM21_08" value="MEM21_08">
<div class="card-wrap"><img src="../Card%20images/General/eCards/MEM21-08_250w.jpg"></div><button type="button">Preview</button>
</label><label class="" for="honor-memorial-design-MEM221_08"><input type="radio" name="product_id" id="honor-memorial-design-MEM221_08" value="MEM221_08">
<div class="card-wrap"><img src="../Card%20images/General/eCards/MEM221-08_250w.jpg"></div><button type="button">Preview</button>
</label></div>
</div>
<div class="honor-memorial-designs honor-memorial-designs--certificate hide">
<div class="honor-memorial-designs-row clearfix"><label class="" for="honor-memorial-design-CR20_01"><input type="radio" name="product_id" id="honor-memorial-design-CR20_01" value="CR20_01">
<div class="card-wrap"><img src="../Card%20images/General/Certficates/CR20-01_250w.jpg"></div><button type="button">Preview</button>
</label></div>
</div>
<!-- tribute ecard fields -->
<div class="honor-memorial-fields honor-memorial-fields--tribute">
<input type="hidden" name="ecard.id" value="">
<h5> Dedicate my gift to: </h5>
<div class="mb-m">
<input type="text" class="input-required--honor-memorial" name="honoree_full_name" id="donation-form__tribute_full_name--tribute" placeholder="Name" maxlength="60">
</div>
<h3> CARD RECIPIENT INFORMATION </h3>
<h5> Recipient Name: </h5>
<div class="clearfix">
<div class="grid_4">
<div class="mb-m">
<input type="text" class="input-required--honor-memorial" name="honoree_first_name" id="donation-form__tribute_first_name--tribute" placeholder="First Name">
</div>
</div>
<div class="grid_4">
<div class="mb-m">
<input type="text" class="input-required--honor-memorial" name="honoree_last_name" id="donation-form__tribute_last_name--tribute" placeholder="Last Name">
</div>
</div>
</div>
<div class="clearfix">
<div class="grid_4">
<div class="mb-m">
<h5> Recipient Email Address: </h5>
<input type="email" class="input-required--honor-memorial" name="ecard.recipients" id="donation-form__ecard-recipients" placeholder="email@domain.com">
</div>
</div>
</div>
<div class="clearfix">
<div class="grid_4">
<div class="mb-m">
<h5> Enter your personal message: </h5>
<textarea rows="4" class="input-required--honor-memorial" name="ecard_message" id="donation-form__tribute-message" maxlength="255" placeholder="255 characters maximum"></textarea>
</div>
</div>
</div>
<h5> Who should we say this card is from? </h5>
<input type="text" class="input-required--honor-memorial" name="from_name" id="donation-form__from_name--tribute" maxlength="27" placeholder="Your Name">
</div>
<!-- memorial ecard fields -->
<div class="honor-memorial-fields honor-memorial-fields--memorial hide">
<input type="hidden" name="ecard.id" value="" disabled="disabled">
<h5> Dedicate my gift to: </h5>
<div class="mb-m">
<input type="text" class="input-required--honor-memorial" name="honoree_full_name" id="donation-form__tribute_full_name--memorial" placeholder="Name" maxlength="60" disabled="disabled">
</div>
<h3> CARD RECIPIENT INFORMATION </h3>
<h5> Recipient Name: </h5>
<div class="clearfix">
<div class="grid_4">
<div class="mb-m">
<input type="text" class="input-required--honor-memorial" name="honoree_first_name" id="donation-form__tribute_first_name--memorial" placeholder="First Name" disabled="disabled">
</div>
</div>
<div class="grid_4">
<div class="mb-m">
<input type="text" class="input-required--honor-memorial" name="honoree_last_name" id="donation-form__tribute_last_name--memorial" placeholder="Last Name" disabled="disabled">
</div>
</div>
</div>
<div class="clearfix">
<div class="grid_4">
<div class="mb-m">
<h5> Recipient Email Address: </h5>
<input type="email" class="input-required--honor-memorial" name="ecard.recipients" id="donation-form__ecard-recipients" placeholder="email@domain.com" disabled="disabled">
</div>
</div>
</div>
<div class="clearfix">
<div class="grid_4">
<div class="mb-m">
<h5> Enter your personal message: </h5>
<textarea rows="4" class="input-required--honor-memorial" name="ecard_message" id="donation-form__memorial-message" maxlength="255" placeholder="255 characters maximum" disabled="disabled"></textarea>
</div>
</div>
</div>
<h5> Who should we say this card is from? </h5>
<input type="text" class="input-required--honor-memorial" name="from_name" id="donation-form__from_name--memorial" maxlength="27" placeholder="Your Name" disabled="disabled">
</div>
<!-- certificate fields -->
<div class="honor-memorial-fields honor-memorial-fields--certificate hide">
<h3> Dedicate my gift to </h3>
<label for="donation-form__tribute_first_name--certificate"> Name </label>
<div class="clearfix">
<div class="grid_4">
<div class="mb-m">
<input type="text" class="input-required--honor-memorial" name="honoree_first_name" id="donation-form__tribute_first_name--certificate" placeholder="First Name" maxlength="19" disabled="disabled">
</div>
</div>
<div class="grid_4">
<div class="mb-m">
<input type="text" class="input-required--honor-memorial" name="honoree_last_name" id="donation-form__tribute_last_name--certificate" placeholder="Last Name" maxlength="19" disabled="disabled">
</div>
</div>
</div>
<label for="donation-form__from_name--certificate"> Who should we say this card is from? </label>
<input type="text" class="input-required--honor-memorial" name="from_name" id="donation-form__from_name--certificate" maxlength="53" placeholder="Your Name" disabled="disabled">
</div>
</div>
</div>
<!-- HIDE FOR TEST ON DEV - MOVE TO DONATION LEVELS -->
<div class="row-fluid">
<!-- THIS IS NEW
calculate one month from today
month + 1 = 3
append the day: 3/14
3
append current year: 3/14/2024
-->
<!-- HIDE FOR TEST ON DEV - MOVE TO DONATION LEVELS -->
<!-- hide monthly checkbox from no-adhoc-form for redesign but maintain logic-->
<div class="hide">
<label class="checkbox-label-btn hide" for="donate-monthly-toggle">
<input type="checkbox" id="donate-monthly-toggle"> Donate Monthly </label>
<div class="clearfix mt-m donate-monthly-info hide" style="">
<div class="grid_12"> Your first donation will be charged today and then monthly starting on 3/14/2024. </div>
<!--<div class="grid_3 hide">
<a class="js--donate-monthly-learn-more" href="https://secure2.wish.org/site/SPageServer?pagename=donate_today&ft=SPEA&fi=24_85&dest=none&Campaign_ID=MNOO%fy%&Appeal_ID=%fy%ON-XXX-APPL&Package_ID=OT-NT-APPLFEBSQ4&Subtype=DEV-Multimedia%20Online&s_src=mw-email-fr&s_subsrc=mw-maw14-02-valentines-day-2024-chapter&level1=75&level2=125&level3=250&mlevel1=20&mlevel2=30&mlevel3=50&presel=level1&utm_campaign=mw-maw14-02-valentines-day-2024-chapter&utm_source=sfmc&utm_medium=email#">Learn more about our monthly donor program and benefits.</a>
</div>-->
</div>
</div>
<!-- BEGIN: REMOVE CONDITIONAL MONTHLY OPTION FROM OPTIONS
<div class="row-fluid">
<label class="checkbox-label-btn" for="donate-monthly-toggle">
<input type="checkbox" id="donate-monthly-toggle">
Donate Monthly
</label>
-->
<!--
calculate one month from today
month + 1 = 3
append the day: 3/14
append current year: 3/14/2024
-->
<!-- BEGIN: REMOVE CONDITIONAL MONTHLY OPTION FROM OPTIONS
<div class="clearfix mt-m donate-monthly-info hide">
<div class="grid_5">
Your first donation will be charged today and then monthly starting on 3/14/2024.
</div>
<div class="grid_3">
<a class="js--donate-monthly-learn-more" href="https://secure2.wish.org/site/SPageServer?pagename=donate_today&ft=SPEA&fi=24_85&dest=none&Campaign_ID=MNOO%fy%&Appeal_ID=%fy%ON-XXX-APPL&Package_ID=OT-NT-APPLFEBSQ4&Subtype=DEV-Multimedia%20Online&s_src=mw-email-fr&s_subsrc=mw-maw14-02-valentines-day-2024-chapter&level1=75&level2=125&level3=250&mlevel1=20&mlevel2=30&mlevel3=50&presel=level1&utm_campaign=mw-maw14-02-valentines-day-2024-chapter&utm_source=sfmc&utm_medium=email#">Learn more about our monthly donor program and benefits.</a>
</div>
</div>
</div>
-->
</div>
</div>
<div id="donor-intent" class="section-panel section-panel--donor-intent clearfix">
<div class="target-global-mbox"></div>
<hr class="hr-style">
<div class="grid_9 three">
<h3 class="section-panel__header"> Donation Designation </h3>
<div id="donor-intent-options">
<div class="row-fluid clearfix">
<label class="radio-label-btn " for="donor-intent-national">
<input type="radio" name="donor_intent_type" id="donor-intent-national" value="national">
<div class="direct-text"> National<br>
<span>Serves children throughout the U.S.</span>
</div>
</label>
<label class="radio-label-btn
" for="donor-intent-local">
<input type="radio" name="donor_intent_type" id="donor-intent-local" value="local">
<div class="direct-text"> Local<br>
<span>Serves children in <span class="chapterName">a specific</span> region.</span>
</div>
</label>
</div>
<div class="donor-intent-options js--donor-intent-local hide">
<h5> Select which Make-A-Wish Chapter you'd like to support: </h5>
<div class="label-error hide">Please select a local chapter</div>
<select class="jsSkipUniform select2-hidden-accessible" id="donor-intent-local-chapter" data-defaultvalue="" data-placeholder="Select your chapter or enter your ZIP Code" data-inputplaceholder="Chapter name or ZIP Code"
tabindex="-1" aria-hidden="true">
<option value="">Select a Chapter</option>
<option value="059-000" data-statesshort="AL" data-stateslong="Alabama">Make-A-Wish® Alabama</option>
<option value="048-000" data-statesshort="AK,WA" data-stateslong="Alaska,Washington">Make-A-Wish® Alaska & Washington</option>
<option value="001-000" data-statesshort="AZ" data-stateslong="Arizona">Make-A-Wish® Arizona</option>
<option value="031-000" data-statesshort="TX" data-stateslong="Texas">Make-A-Wish® Central & South Texas</option>
<option value="047-000" data-statesshort="NC" data-stateslong="North Carolina">Make-A-Wish® Central & Western North Carolina</option>
<option value="080-000" data-statesshort="FL" data-stateslong="Florida">Make-A-Wish® Central and Northern Florida</option>
<option value="039-000" data-statesshort="CA" data-stateslong="California">Make-A-Wish® Central Coast and Southern Central Valley</option>
<option value="033-000" data-statesshort="NY" data-stateslong="New York">Make-A-Wish® Central New York</option>
<option value="009-000" data-statesshort="CO" data-stateslong="Colorado">Make-A-Wish® Colorado</option>
<option value="054-000" data-statesshort="CT" data-stateslong="Connecticut">Make-A-Wish® Connecticut</option>
<option value="068-000" data-statesshort="TN" data-stateslong="Tennessee">Make-A-Wish® East Tennessee</option>
<option value="064-000" data-statesshort="NC" data-stateslong="North Carolina">Make-A-Wish® Eastern North Carolina</option>
<option value="081-000" data-statesshort="GA" data-stateslong="Georgia">Make-A-Wish® Georgia</option>
<option value="025-000" data-statesshort="CA" data-stateslong="California">Make-A-Wish® Greater Bay Area</option>
<option value="015-000" data-statesshort="CA" data-stateslong="California">Make-A-Wish® Greater Los Angeles</option>
<option value="008-000" data-statesshort="PA,WV" data-stateslong="Pennsylvania,West Virginia">Make-A-Wish® Greater Pennsylvania and West Virginia, Inc.</option>
<option value="067-000" data-statesshort="VA" data-stateslong="Virginia">Make-A-Wish® Greater Virginia</option>
<option value="077-000" data-statesshort="GU" data-stateslong="Guam">Make-A-Wish® Guam and CNMI</option>
<option value="013-000" data-statesshort="HI" data-stateslong="Hawaii">Make-A-Wish® Hawaii</option>
<option value="053-000" data-statesshort="NY" data-stateslong="New York">Make-A-Wish® Hudson Valley</option>
<option value="056-000" data-statesshort="ID" data-stateslong="Idaho">Make-A-Wish® Idaho</option>
<option value="045-000" data-statesshort="IL" data-stateslong="Illinois">Make-A-Wish® Illinois</option>
<option value="065-000" data-statesshort="IA" data-stateslong="Iowa">Make-A-Wish® Iowa</option>
<option value="079-000" data-statesshort="ME" data-stateslong="Maine">Make-A-Wish® Maine</option>
<option value="066-000" data-statesshort="MA,RI" data-stateslong="Massachusetts,Rhode Island">Make-A-Wish® Massachusetts and Rhode Island</option>
<option value="010-000" data-statesshort="NY" data-stateslong="New York">Make-A-Wish® Metro New York and Western New York</option>
<option value="022-000" data-statesshort="MI" data-stateslong="Michigan">Make-A-Wish® Michigan</option>
<option value="016-000" data-statesshort="DC,MD,VA" data-stateslong="District of Columbia,Maryland,Virginia">Make-A-Wish® Mid-Atlantic, Inc.</option>
<option value="049-000" data-statesshort="AR,AR,MS,TN" data-stateslong="Arkansas,Arkansas,Mississippi,Tennessee">Make-A-Wish® Mid-South</option>
<option value="085-000" data-statesshort="TN" data-stateslong="Tennessee">Make-A-Wish® Middle Tennessee</option>
<option value="030-000" data-statesshort="MN" data-stateslong="Minnesota">Make-A-Wish® Minnesota</option>
<option value="036-000" data-statesshort="MS" data-stateslong="Mississippi">Make-A-Wish® Mississippi</option>
<option value="073-000" data-statesshort="KS,MO" data-stateslong="Kansas,Missouri">Make-A-Wish® Missouri & Kansas</option>
<option value="018-000" data-statesshort="NE" data-stateslong="Nebraska">Make-A-Wish® Nebraska</option>
<option value="058-000" data-statesshort="NH" data-stateslong="New Hampshire">Make-A-Wish® New Hampshire</option>
<option value="003-000" data-statesshort="NJ" data-stateslong="New Jersey">Make-A-Wish® New Jersey</option>
<option value="057-000" data-statesshort="NM" data-stateslong="New Mexico">Make-A-Wish® New Mexico, Inc.</option>
<option value="050-000" data-statesshort="ND" data-stateslong="North Dakota">Make-A-Wish® North Dakota</option>
<option value="006-000" data-statesshort="TX" data-stateslong="Texas">Make-A-Wish® North Texas</option>
<option value="060-000" data-statesshort="NY" data-stateslong="New York">Make-A-Wish® Northeast New York</option>
<option value="012-000" data-statesshort="CA,NV" data-stateslong="California,Nevada">Make-A-Wish® Northeastern & Central California and Northern Nevada</option>
<option value="011-000" data-statesshort="IN,IN,KY,OH" data-stateslong="Indiana,Indiana,Kentucky,Ohio">Make-A-Wish® Ohio, Kentucky & Indiana</option>
<option value="063-000" data-statesshort="OK" data-stateslong="Oklahoma">Make-A-Wish® Oklahoma</option>
<option value="007-000" data-statesshort="CA" data-stateslong="California">Make-A-Wish® Orange County & the Inland Empire</option>
<option value="005-000" data-statesshort="OR,WA" data-stateslong="Oregon,Washington">Make-A-Wish® Oregon</option>
<option value="051-000" data-statesshort="DE,PA" data-stateslong="Delaware,Pennsylvania">Make-A-Wish® Philadelphia, Delaware & Susquehanna Valley</option>
<option value="071-000" data-statesshort="PR" data-stateslong="Puerto Rico">Make-A-Wish® Puerto Rico</option>
<option value="084-000" data-statesshort="TX" data-stateslong="Texas">Make-A-Wish® Rio Grande Valley</option>
<option value="024-000" data-statesshort="CA" data-stateslong="California">Make-A-Wish® San Diego</option>
<option value="034-000" data-statesshort="SC" data-stateslong="South Carolina">Make-A-Wish® South Carolina</option>
<option value="027-000" data-statesshort="MT,MT,SD,SD" data-stateslong="Montana,Montana,South Dakota,South Dakota">Make-A-Wish® South Dakota & Montana</option>
<option value="017-000" data-statesshort="FL" data-stateslong="Florida">Make-A-Wish® Southern Florida, Inc.</option>
<option value="083-000" data-statesshort="NV" data-stateslong="Nevada">Make-A-Wish® Southern Nevada</option>
<option value="035-000" data-statesshort="LA,TX" data-stateslong="Louisiana,Texas">Make-A-Wish® Texas Gulf Coast & Louisiana</option>
<option value="017-002" data-statesshort="VI" data-stateslong="Virgin Islands">Make-A-Wish® U.S. Virgin Islands</option>
<option value="042-000" data-statesshort="UT" data-stateslong="Utah">Make-A-Wish® Utah</option>
<option value="069-000" data-statesshort="VT" data-stateslong="Vermont">Make-A-Wish® Vermont</option>
<option value="010-002" data-statesshort="NY" data-stateslong="New York">Make-A-Wish® Western New York</option>
<option value="029-000" data-statesshort="WI" data-stateslong="Wisconsin">Make-A-Wish® Wisconsin</option>
<option value="043-000" data-statesshort="WY" data-stateslong="Wyoming">Make-A-Wish® Wyoming</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 100px;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox" aria-autocomplete="list"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-labelledby="select2-donor-intent-local-chapter-container"><span class="select2-selection__rendered" id="select2-donor-intent-local-chapter-container"><span
class="select2-selection__placeholder">Select your chapter or enter your ZIP Code</span></span><span class="select2-selection__arrow" role="presentation"><b role="presentation"></b></span></span></span><span
class="dropdown-wrapper" aria-hidden="true"></span></span>
</div>
<div class="row-fluid clearfix show--xs js--international-row-xs"></div>
<div class="donor-intent-options js--donor-intent-international hide">
<h5> Select which Make-A-Wish Chapter you'd like to support: </h5>
<div class="label-error hide">Please select an international chapter</div>
<select class="jsSkipUniform select2-hidden-accessible" id="donor-intent-international-chapter" data-defaultvalue="" data-placeholder="Select a Country" data-inputplaceholder="Country" tabindex="-1" aria-hidden="true">
<option value="">Select a Country</option>
<option value="500-000"
data-countrieslong="Argentina,Australia,Austria,Belgium South,Belgium Vlaanderen,Brazil,Canada,Chile,China,Colombia,Denmark,France,Germany,Greece,Hong Kong,India,Ireland,Israel,Italy ,Japan,Korea,Malaysia,Mexico,New Zealand,Norway,Pakistan,Panama,Peru,Philippines,Portugal,Singapore,Spain,Switzerland,Taiwan,The Netherlands,The Pacific Islands,Turkey,United Arab Emirates,United Kingdom">
Make-A-Wish® International</option>
<option value="526-000" data-countrieslong="Argentina">Make-A-Wish® Argentina</option>
<option value="503-000" data-countrieslong="Australia">Make-A-Wish® Australia</option>
<option value="514-000" data-countrieslong="Austria">Make-A-Wish® Austria</option>
<option value="510-000" data-countrieslong="Belgium South">Make-A-Wish® Belgium South</option>
<option value="511-000" data-countrieslong="Belgium Vlaanderen">Make-A-Wish® Belgium Vlaanderen</option>
<option value="532-000" data-countrieslong="Brazil">Make-A-Wish® Brazil</option>
<option value="501-000" data-countrieslong="Canada">Make-A-Wish® Canada</option>
<option value="508-000" data-countrieslong="Chile">Make-A-Wish® Chile</option>
<option value="543-000" data-countrieslong="Colombia">Make-A-Wish® Colombia</option>
<option value="521-000" data-countrieslong="Denmark">Make-A-Wish® Denmark</option>
<option value="522-000" data-countrieslong="France">Make-A-Wish® France</option>
<option value="531-000" data-countrieslong="Germany">Make-A-Wish® Germany</option>
<option value="515-000" data-countrieslong="Greece">Make-A-Wish® Greece</option>
<option value="516-000" data-countrieslong="Hong Kong">Make-A-Wish® Hong Kong</option>
<option value="517-000" data-countrieslong="India">Make-A-Wish® India</option>
<option value="505-000" data-countrieslong="Ireland">Make-A-Wish® Ireland</option>
<option value="512-000" data-countrieslong="Israel">Make-A-Wish® Israel</option>
<option value="528-000" data-countrieslong="Italy ">Make-A-Wish® Italy </option>
<option value="506-000" data-countrieslong="Japan">Make-A-Wish® Japan</option>
<option value="527-000" data-countrieslong="Korea">Make-A-Wish® Korea</option>
<option value="536-000" data-countrieslong="Malaysia">Make-A-Wish® Malaysia</option>
<option value="518-000" data-countrieslong="Mexico">Make-A-Wish® Mexico</option>
<option value="509-000" data-countrieslong="The Netherlands">Make-A-Wish® Netherlands</option>
<option value="504-000" data-countrieslong="New Zealand">Make-A-Wish® New Zealand</option>
<option value="540-000" data-countrieslong="Norway">Make-A-Wish® Norway</option>
<option value="541-000" data-countrieslong="The Pacific Islands">Make-A-Wish® Pacific Islands</option>
<option value="534-000" data-countrieslong="Pakistan">Make-A-Wish® Pakistan</option>
<option value="513-000" data-countrieslong="Panama">Make-A-Wish® Panama</option>
<option value="530-000" data-countrieslong="Peru">Make-A-Wish® Peru</option>
<option value="520-000" data-countrieslong="Philippines">Make-A-Wish® Philippines</option>
<option value="529-000" data-countrieslong="Portugal">Make-A-Wish® Portugal</option>
<option value="542-000" data-countrieslong="China">Make-A-Wish® Shanghai</option>
<option value="523-000" data-countrieslong="Singapore">Make-A-Wish® Singapore</option>
<option value="535-000" data-countrieslong="Spain">Make-A-Wish® Spain</option>
<option value="524-000" data-countrieslong="Switzerland">Make-A-Wish® Switzerland and Liechtenstein</option>
<option value="507-000" data-countrieslong="Taiwan">Make-A-Wish® Taiwan</option>
<option value="533-000" data-countrieslong="Turkey">Make-A-Wish® Turkey</option>
<option value="525-000" data-countrieslong="United Arab Emirates">Make-A-Wish® United Arab Emirates</option>
<option value="502-000" data-countrieslong="United Kingdom">Make-A-Wish® United Kingdom</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 100px;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox" aria-autocomplete="list"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-labelledby="select2-donor-intent-international-chapter-container"><span class="select2-selection__rendered"
id="select2-donor-intent-international-chapter-container"><span class="select2-selection__placeholder">Select a Country</span></span><span class="select2-selection__arrow"
role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</div>
</div>
</div>
</div>
<div id="addtl_info" class="hide">
<label>Additional Info</label>
<input type="text" name="misc_info" id="misc_info" value="">
</div>
</div>
</div>
</div>
<div class="donation-step donation-step--2">
<div class="section-panel section-panel--donor-info" data-consid="">
<div class="grid_9 three">
<h3 class="section-panel__header"> Your Information </h3>
<div class="row-fluid">
<h5> Your Name </h5>
<div class="clearfix">
<div class="grid_4">
<div class="mb-m">
<input type="text" class="input-required" name="donor.name.first" id="donation-form__donor-name-first" value="" placeholder="First Name" aria-required="true">
</div>
</div>
<div class="grid_4">
<div class="mb-m">
<input type="text" class="input-required" name="donor.name.last" id="donation-form__donor-name-last" value="" placeholder="Last Name" aria-required="true">
</div>
</div>
</div>
</div>
<div class="row-fluid">
<div class="clearfix">
<div class="grid_4">
<div class="mb-m">
<h5> Street Address 1 </h5>
<input type="text" class="input-required" name="donor.address.street1" id="donation-form__donor-address-street1" value="" placeholder="0000 NE 00 Ave" aria-required="true">
</div>
</div>
<div class="grid_4">
<div class="mb-m">
<h5> Street Address 2 (Optional) </h5>
<input type="text" name="donor.address.street2" id="donation-form__donor-address-street2" value="" placeholder="#00">
</div>
</div>
</div>
</div>
<div class="row-fluid" style="display:none;">
<h5> Employer Name </h5>
<div class="clearfix">
<div class="grid_4">
<div class="mb-m">
<input type="text" class="input-required" name="donor.employer" id="donation-form__donor-employer-name" value="dc:employer" placeholder="Employer Name" aria-required="true">
</div>
</div>
</div>
</div>
<div class="row-fluid">
<div class="clearfix">
<div class="grid_3">
<h5> Postal Code </h5>
<div class="mb-m">
<input type="text" class="input-required js--zip-map-postal-code" name="donor.address.zip" id="donation-form__donor-address-zip" value="" placeholder="00000" data-mappedcity="#donation-form__donor-address-city"
data-mappedstate="#donation-form__donor-address-state" aria-required="true">
</div>
</div>
<div class="grid_3 js--zip-map-city hide">
<h5> City </h5>
<div class="mb-m">
<input type="text" class="input-required" name="donor.address.city" id="donation-form__donor-address-city" value="" placeholder="City" aria-required="true">
</div>
</div>
<div class="grid_3 js--zip-map-state hide">
<h5> State/Province </h5>
<div class="mb-m">
<select class="input-required" data-blanktext="Select a State" name="donor.address.state" id="donation-form__donor-address-state" size="1" aria-required="true">
<option value="">Select a State</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.address.state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor.address.state_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
</div>
</div>
</div>
</div>
<div class="row-fluid">
<h5> Email Address </h5>
<div class="clearfix">
<div class="grid_4">
<div class="mb-m">
<input type="email" class="input-required" name="donor.email" id="donation-form__donor-email" value="" placeholder="your_email@domain.com" aria-required="true">
</div>
</div>
<div class="grid_4">
<div class="mb-m">
<label class="checkbox-label-btn" for="donation-form__donor-email_opt_in"> Donors receive periodic updates and communications from Make-A-Wish and may unsubscribe at any time. <input type="hidden" name="donor.email_opt_in"
id="donation-form__donor-email_opt_in" value="true">
</label>
</div>
</div>
</div>
</div>
<div id="company-matching" class="row-fluid">
<h5> Employer </h5>
<div class="clearfix">
<div class="grid_4">
<div class="mb-m">
<input type="hidden" name="double_the_donation_company_id" id="double_the_donation_company_id" value="">
<script src="https://doublethedonation.com/api/js/ddplugin.js"></script>
<link href="https://doublethedonation.com/api/css/ddplugin.css" rel="stylesheet">
<style>
#dd-company-name-input .Select-menu,
.dtd-streamlined-plugin .Select-menu {
overflow-y: visible !important;
}
#dd-company-name-input .dtd-search-input,
.dtd-streamlined-plugin .dtd-search-input {
background-color: #ebebeb !important;
}
.content-row p.dd-company-selected {
font-size: 13px;
}
.wrongcompany {
display: block;
}
.section-panel--donor-info .grid_9,
.section-panel--donor-info .grid_4 {
overflow: visible;
}
</style>
<div class="mb-m" id="dd-company-name-input"></div>
<script type="text/javascript">
Y.use('jquery-noconflict', function() {
jQuery(document).ready(function() {
jQuery(document).on("doublethedonation_company_id", function() {
setTimeout(function() {
var dtd_company_id = jQuery('input[name=doublethedonation_company_id]').val();
jQuery("#double_the_donation_company_id").val(dtd_company_id);
console.log("company id changed", jQuery("input[name=doublethedonation_company_id]").val());
}, 1000);
});
});
});
</script>
</div>
</div>
<div class="grid_4">
<div class="mb-m">
<label class="checkbox-label-btn" for="donation-form__donor-email_opt_in"> Check to see if your employer will match your donation. </label>
</div>
</div>
</div>
</div>
<div class="hide">
<select class="jsSkipUniform" name="donor.address.country" id="donation-form__donor-address-country" size="1">
<option></option>
<option 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.address.country', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor.address.country_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
</div>
</div>
</div>
<div class="section-panel clearfix">
<div class="grid_9 three">
<h3 class="section-panel__header"> Your Payment Information </h3>
<div class="row-fluid payment-type-row mb-m clearfix">
<label class="radio-label-btn selected" for="payment-type-credit">
<input type="radio" name="payment_type" id="payment-type-credit" value="credit" checked=""> Credit Card </label>
<label class="radio-label-btn" for="payment-type-paypal">
<input type="radio" name="payment_type" id="payment-type-paypal" value="paypal"> Paypal </label>
</div>
<div class="hidden">
<div class="row-fluid mt-m">
<label class="checkbox-label-btn" for="billing-info-different-toggle">
<input type="checkbox" name="billing_info_is_different" id="billing-info-different-toggle"> Enter different Billing Info </label>
</div>
<div class="js--billing-info hide" style="">
<div class="row-fluid mt-m">
<h5> Billing Name </h5>
<div class="clearfix">
<div class="grid_4">
<div class="mb-m">
<input type="text" name="billing.name.first" id="donation-form__billing-name-first" placeholder="First Name" disabled="disabled">
</div>
</div>
<div class="grid_4">
<div class="mb-m">
<input type="text" name="billing.name.last" id="donation-form__billing-name-last" placeholder="Last Name" disabled="disabled">
</div>
</div>
</div>
</div>
<div class="row-fluid">
<div class="clearfix">
<div class="grid_4">
<div class="mb-m">
<h5> Street Address 1 </h5>
<input type="text" name="billing.address.street1" id="donation-form__billing-address-street1" placeholder="0000 NE 00 Ave" disabled="disabled">
</div>
</div>
<div class="grid_4">
<div class="mb-m">
<h5> Street Address 2 (Optional) </h5>
<input type="text" name="billing.address.street2" id="donation-form__billing-address-street2" placeholder="#00" disabled="disabled">
</div>
</div>
</div>
</div>
<div class="row-fluid">
<div class="clearfix">
<div class="grid_3">
<h5> Postal Code </h5>
<input type="text" class="js--zip-map-postal-code" name="billing.address.zip" id="donation-form__billing-address-zip" placeholder="00000" data-mappedcity="#donation-form__billing-address-city"
data-mappedstate="#donation-form__billing-address-state" disabled="disabled">
</div>
<div class="grid_3 js--zip-map-city hide">
<h5> City </h5>
<input type="text" name="billing.address.city" id="donation-form__billing-address-city" placeholder="City" disabled="disabled">
</div>
<div class="grid_3 js--zip-map-state hide">
<h5> State/Province </h5>
<select data-blanktext="Select a State" name="billing.address.state" id="donation-form__billing-address-state" size="1" disabled="disabled">
<option value="">Select a State</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.address.state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing.address.state_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
</div>
</div>
</div>
<div class="hide">
<select class="jsSkipUniform" name="billing.address.country" id="donation-form__billing-address-country" size="1" disabled="disabled">
<option></option>
<option 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>
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<noscript><br>Required</noscript>
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</div>
</div>
<div class="js--credit-card-info">
<div class="row-fluid mt-m">
<h5> Credit Card Number </h5>
<div class="clearfix">
<div class="grid_6">
<input type="text" class="input-required--credit input-number" value="" name="card_number" id="donation-form__card_number" placeholder="0000-0000-0000-0000" autocomplete="off" aria-required="true">
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<div class="grid_3">
<div class="card-grid">
<img class="visa" src="../assets/images/form-cc-visa.png" alt="Visa">
<img class="mc" src="../assets/images/form-cc-mastercard.png" alt="MasterCard">
<img class="amex" src="../assets/images/form-cc-amex.png" alt="American Express">
<img class="discover" src="../assets/images/form-cc-discover.png" alt="Discover">
</div>
</div>
</div>
</div>
<div class="row-fluid mt-m">
<div class="clearfix">
<div class="grid_3 credit-card-exp-month-wrap">
<h5> Expiration Date </h5>
<select class="input-required--credit" name="card_exp_date_month" id="donation-form__card_exp_date_month" autocomplete="off" aria-required="true">
<option value="">Month</option>
<option value="01">1</option>
<option value="02">2</option>
<option value="03">3</option>
<option value="04">4</option>
<option value="05">5</option>
<option value="06">6</option>
<option value="07">7</option>
<option value="08">8</option>
<option value="09">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
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<div class="grid_3 credit-card-exp-year-wrap">
<h5> </h5>
<select class="input-required--credit" name="card_exp_date_year" id="donation-form__card_exp_date_year" autocomplete="off" aria-required="true">
<option value="">Year</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>
<option value="2034">2034</option>
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</div>
<div class="grid_3">
<div class="credit-card-cvv-wrap">
<h5> CVV </h5>
<input type="text" class="input-required--credit input-number" value="" name="card_cvv" id="donation-form__card_cvv" placeholder="CVV" autocomplete="off" aria-required="true">
</div>
<a href="https://secure2.wish.org/site/SPageServer?pagename=donate_today&ft=SPEA&fi=24_85&dest=none&Campaign_ID=MNOO%fy%&Appeal_ID=%fy%ON-XXX-APPL&Package_ID=OT-NT-APPLFEBSQ4&Subtype=DEV-Multimedia%20Online&s_src=mw-email-fr&s_subsrc=mw-maw14-02-valentines-day-2024-chapter&level1=75&level2=125&level3=250&mlevel1=20&mlevel2=30&mlevel3=50&presel=level1&utm_campaign=mw-maw14-02-valentines-day-2024-chapter&utm_source=sfmc&utm_medium=email#" class="whats-this js--cvv-whats-this">
What's This?
</a>
</div>
</div>
</div>
</div>
</div>
</div>
<div id="addtl_info2" class="hide">
<label>Additional Info</label>
<input type="text" name="misc_info2" id="misc_info2" value="">
</div>
<div class="section-panel section-panel--donation-submit-buttons clearfix">
<div class="donation-submit-buttons grid_9">
<button type="submit" id="button-submit" class="button-submit">
<span class="js--donation-button-label">Submit Donation</span> <span class="js--donation-amount-selected">$75</span>
</button>
</div>
</div>
<div class="donation-seals">
<span>
<a href="http://wish.org/about-us/making-a-difference/managing-funds/better-business-bureau" target="_blank">
<img src="../make-a-wish-luminate-donate/images/BBB.jpg" alt="BBB" height="159">
</a>
</span>
<span>
<img src="../make-a-wish-luminate-donate/images/Most_Trusted_Nonprofit_Badge_200.png" alt="Most Trusted Nonprofit" width="150">
</span>
<span id="vs_seal">
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<div class="hide">
<div id="js-prod-personalizer">
<div class="top-actions clearfix">
<a href="https://secure2.wish.org/site/SPageServer?pagename=donate_today&ft=SPEA&fi=24_85&dest=none&Campaign_ID=MNOO%fy%&Appeal_ID=%fy%ON-XXX-APPL&Package_ID=OT-NT-APPLFEBSQ4&Subtype=DEV-Multimedia%20Online&s_src=mw-email-fr&s_subsrc=mw-maw14-02-valentines-day-2024-chapter&level1=75&level2=125&level3=250&mlevel1=20&mlevel2=30&mlevel3=50&presel=level1&utm_campaign=mw-maw14-02-valentines-day-2024-chapter&utm_source=sfmc&utm_medium=email#" class="cancel-btn js--prod-personalizer-cancel">
Close
</a>
</div>
<h1> Preview </h1>
<div class="lightbox-body">
<div class="clearfix" id="step2">
<div class="lightbox-leftside">
<div class="productImageContainer" style="position: relative;"></div>
<img alt="" src="../assets/images/hover-zoom.png" class="zoom-link">
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<div class="lightbox-rightside">
<div class="card-thumbs clearfix show--xs"></div>
<div class="cardDescription"></div>
<div class="card-thumbs clearfix hide--xs"></div>
</div>
</div>
</div>
</div>
<div id="js-learn-more">
<div class="row_8 modal clearfix">
<div class="modal-header clearfix">
<div class="grid_4">
<h2> Benefits of membership </h2>
</div>
<div class="grid_2">
<a href="https://secure2.wish.org/site/SPageServer?pagename=donate_today&ft=SPEA&fi=24_85&dest=none&Campaign_ID=MNOO%fy%&Appeal_ID=%fy%ON-XXX-APPL&Package_ID=OT-NT-APPLFEBSQ4&Subtype=DEV-Multimedia%20Online&s_src=mw-email-fr&s_subsrc=mw-maw14-02-valentines-day-2024-chapter&level1=75&level2=125&level3=250&mlevel1=20&mlevel2=30&mlevel3=50&presel=level1&utm_campaign=mw-maw14-02-valentines-day-2024-chapter&utm_source=sfmc&utm_medium=email#" class="cancel-btn js--donate-monthly-learn-more-cancel">
Close
</a>
</div>
</div>
<div class="modal-body clearfix">
<div class="rich-text">
<ol style="list-style-type: disc;">
<li> Great satisfaction. You will know you are helping wishes come true every month. </li>
<li> Convenience. When you participate, your gift will be transferred and will appear each month on your credit card or checking account statement. </li>
<li> Flexibility. If for any reason you wish to increase, decrease or suspend your gifts, just call (800) 722-9474, ext. 3312, and we will gladly accommodate you. </li>
<li> Reduced paperwork and overhead expenses. Automatic monthly payments mean more of your donation goes to granting wishes. </li>
<li> Make-A-Wish calendar. You will receive a year of inspiring photos to warm your heart. </li>
<li> Periodic updates. You'll get ongoing new stories and information via mail or email. </li>
</ol>
</div>
</div>
</div>
</div>
<div id="js-whats-this">
<div class="row_8 modal clearfix">
<div class="modal-header clearfix">
<div class="grid_4">
<h2> Security code </h2>
</div>
<div class="grid_2">
<a href="https://secure2.wish.org/site/SPageServer?pagename=donate_today&ft=SPEA&fi=24_85&dest=none&Campaign_ID=MNOO%fy%&Appeal_ID=%fy%ON-XXX-APPL&Package_ID=OT-NT-APPLFEBSQ4&Subtype=DEV-Multimedia%20Online&s_src=mw-email-fr&s_subsrc=mw-maw14-02-valentines-day-2024-chapter&level1=75&level2=125&level3=250&mlevel1=20&mlevel2=30&mlevel3=50&presel=level1&utm_campaign=mw-maw14-02-valentines-day-2024-chapter&utm_source=sfmc&utm_medium=email#" class="cancel-btn js--cvv-whats-this-cancel">
Close
</a>
</div>
</div>
<div class="modal-body clearfix">
<div class="rich-text">
<h3> What is a card security code? </h3>
<p> The Card Security Code (CSC) is a 3- or 4-digit number printed on your credit card. It provides added security when you use your card on the Internet or over the phone. The number appears only on the card itself, not on receipts or
statements. </p>
<p> We ask for the CSC when you enter your payment information. This helps ensure that anyone making a donation to the Make-A-Wish Foundation has the card in his or her possession and is not using a stolen credit card number. </p>
<div class="left">
<h3> For Visa, Mastercard and Discover cards </h3>
<p> Turn the card over and look at the signature box. You will find either the entire 16-digit credit card number or just the last 4 digits, followed by the 3-digit CSC. </p>
<img alt="" src="../assets/images/csc_visamc.png">
</div>
<div class="right">
<h3> For American Express cards </h3>
<p> The CSC is always located above the account number on the face of the card, sometimes on the left side and sometimes on the right. Note: Some American Express cards have a 4-digit number below the account number. This is not the
CSC. </p>
<img alt="" src="../assets/images/csc_amex.png">
</div>
</div>
</div>
</div>
</div>
<div id="js-ach-whats-this">
<div class="row_8 modal clearfix">
<div class="modal-header clearfix">
<div class="grid_4">
<h2> Bank Account Information </h2>
</div>
</div>
<div class="modal-body clearfix">
<div class="rich-text">
<p>Your bank information can be found on your check at the bottom. It will look similar to the following:</p>
<img src="../make-a-wish-luminate-donate/images/donation-form/routing_ach_location.jpg" class="modal-graphic" alt="">
</div>
</div>
</div>
</div>
<div class="js--donation-processing-modal">
<div class="fb-modal showGraphic">
<span class="modal-message">Transaction Processing</span>
<img src="../make-a-wish-luminate-donate/img/global/prog-spinner3.gif" class="modal-graphic" alt="">
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</div>
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text-decoration: none;
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<div id="don-upsell-modal" class="fc-content">
<div class="modal-image"></div>
<div class="modal-header">
<h1>Make It Monthly</h1>
</div>
<div class="modal-body">
<p>Would you consider a monthly gift of <span id="newMonthlyAmt"></span> instead to support granting wishes for kids?</p>
<button id="yes-please" data-value="1" data-fancybox-close="">Yes, I'll make a monthly gift of <span id="newMonthlyAmtBtn"></span></button>
<div><a data-value="0" data-fancybox-close="" href="javascript:;">No thanks, I prefer to make a single gift of <span id="currentSingleGift"></span></a></div>
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afterClose: function(instance, current, e) {
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var button = e ? e.target || e.currentTarget : null;
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</script>
<style>
.fancybox-inner h1 {
font-size: 2rem;
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.modal-body {
text-align: center;
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.modal-body p {
font-size: 1rem;
margin-bottom: 25px;
}
button#yes-please {
display: block;
margin: 10px auto;
background: #0055b7;
color: #fff;
border: 0;
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min-height: 34px;
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font-size: 1.2rem;
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button:focus {
outline: 0;
}
#no-thanks {
display: block;
font-size: 1rem;
text-decoration: none;
}
</style>
<div id="drtv-don-upsell-modal" class="fc-content">
<div class="modal-image"></div>
<div class="modal-header">
<h1>Make It Monthly</h1>
</div>
<div class="modal-body">
<p>Would you consider a monthly gift of <span id="newMonthlyAmt"></span> instead to support granting wishes for kids?</p>
<button id="yes-please" data-value="1" data-fancybox-close="">Yes, I'll make a monthly gift of <span id="newMonthlyAmtBtn"></span></button>
<div><a data-value="0" data-fancybox-close="" href="javascript:;">No thanks, I prefer to make a single gift of <span id="currentSingleGift"></span></a></div>
</div>
</div>
<script>
(function($) {
$.fancyConfirm = function(opts) {
opts = $.extend(true, {
title: 'Are you sure?',
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okButton: 'OK',
noButton: 'Cancel',
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closeBtn: true,
clickOutside: true,
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}
});
}
})(jQuery);
</script>
<style>
.paper-message {
display: block !important;
}
</style>
<div id="don-paper-message-modal" class="fc-content">
<div id="papercard-warning" class="fc-content">
<div class="modal-header">
<h1>Will You Consider Sending An E-Card?</h1>
</div>
<div class="modal-body">
<p>To ensure every dollar of your donation goes to helping grant more wishes, processing times for paper cards may be delayed up to 6 weeks. Sending an ecard will notify your recipient today.</p>
<div class="links"><button id="yes-please" data-value="1" data-fancybox-close="">Yes, I'll send an e-card instead</button>
<a data-value="0" data-fancybox-close="" href="javascript:;">I prefer to send a physical card</a>
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</div>
</div>
</div>
<script>
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$('.honor-memorial-designs--card .paper-message').remove();
$('.honor-memorial-designs--card').prepend(
'<div class="paper-message alert alert-danger">To ensure every dollar of your donation goes to helping grant more wishes, processing times for paper cards may be delayed up to 6 weeks. Sending an ecard will notify your recipient today.</div>'
);
}
});
})(jQuery);
</script>
</div>
</div>
</form>Text Content
Contact Us Donate with Crypto Donate by Mail
DONATE TODAY
In honor of American Heart Month, make a gift to help grant wishes for kids with
heart conditions and other critical illnesses. Donate now to provide more kids
with the hope and strength of a wish.
YOUR DONATION
One-Time Gift Monthly Gift
Select your donation amount:
$75 $125 $250
$20 $30 $50
Your first donation will be charged today and then monthly starting on
3/14/2024.
CHANGE DONATION TYPE
Make this an honor / memorial gift
HONOR / MEMORIAL INFORMATION
Select your card type and design:
Ecard - In Honor Of Ecard - Memorial Printable Certificate
Preview
Preview
Preview
Preview
Preview
DEDICATE MY GIFT TO:
CARD RECIPIENT INFORMATION
RECIPIENT NAME:
RECIPIENT EMAIL ADDRESS:
ENTER YOUR PERSONAL MESSAGE:
WHO SHOULD WE SAY THIS CARD IS FROM?
DEDICATE MY GIFT TO:
CARD RECIPIENT INFORMATION
RECIPIENT NAME:
RECIPIENT EMAIL ADDRESS:
ENTER YOUR PERSONAL MESSAGE:
WHO SHOULD WE SAY THIS CARD IS FROM?
DEDICATE MY GIFT TO
Name
Who should we say this card is from?
Donate Monthly
Your first donation will be charged today and then monthly starting on
3/14/2024.
--------------------------------------------------------------------------------
DONATION DESIGNATION
National
Serves children throughout the U.S.
Local
Serves children in a specific region.
SELECT WHICH MAKE-A-WISH CHAPTER YOU'D LIKE TO SUPPORT:
Please select a local chapter
Select a Chapter Make-A-Wish® AlabamaMake-A-Wish® Alaska &
WashingtonMake-A-Wish® ArizonaMake-A-Wish® Central & South TexasMake-A-Wish®
Central & Western North CarolinaMake-A-Wish® Central and Northern
FloridaMake-A-Wish® Central Coast and Southern Central ValleyMake-A-Wish®
Central New YorkMake-A-Wish® ColoradoMake-A-Wish® ConnecticutMake-A-Wish® East
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Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia
Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize
Benin Bermuda Bhutan Bolivarian Republic of Venezuela Bonaire, Sint Eustatios
and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian
Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia
Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile
China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook
Islands Costa Rica Cote D'Ivoire Croatia Cuba Curacao Cyprus Czech Republic
Democratic People's Republic of Korea The Democratic Republic of the Congo
Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador
Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe
Islands Federated States of Micronesia Fiji Finland The Former Yugoslav Republic
of Macedonia France French Guiana French Polynesia French Southern Territories
Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe
Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and
McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary
Iceland India Indonesia Iraq Ireland Islamic Republic of Iran Isle of Man Israel
Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan
Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya
Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives
Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico
Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru
Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk
Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian
Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn
Plurinational State of Bolivia Poland Portugal Puerto Rico Qatar Republic of
Korea Republic of Moldova Reunion Romania Russian Federation Rwanda Saint
Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis
Saint Lucia Saint Martin (French) Saint Pierre and Miquelon Saint Vincent and
the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal
Serbia Seychelles S. Georgia & S. Sandwich Isls. Sierra Leone Singapore Sint
Maarten (Dutch) Slovakia Slovenia Solomon Islands Somalia South Africa South
Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden
Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Thailand
Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan
Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United
Kingdom United Republic of Tanzania Uruguay USA Minor Outlying Islands
Uzbekistan Vanuatu Viet Nam Virgin Islands (British) Virgin Islands (USA) Wallis
and Futuna Western Sahara Yemen Zambia Zimbabwe
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BENEFITS OF MEMBERSHIP
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1. Great satisfaction. You will know you are helping wishes come true every
month.
2. Convenience. When you participate, your gift will be transferred and will
appear each month on your credit card or checking account statement.
3. Flexibility. If for any reason you wish to increase, decrease or suspend
your gifts, just call (800) 722-9474, ext. 3312, and we will gladly
accommodate you.
4. Reduced paperwork and overhead expenses. Automatic monthly payments mean
more of your donation goes to granting wishes.
5. Make-A-Wish calendar. You will receive a year of inspiring photos to warm
your heart.
6. Periodic updates. You'll get ongoing new stories and information via mail or
email.
SECURITY CODE
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WHAT IS A CARD SECURITY CODE?
The Card Security Code (CSC) is a 3- or 4-digit number printed on your credit
card. It provides added security when you use your card on the Internet or over
the phone. The number appears only on the card itself, not on receipts or
statements.
We ask for the CSC when you enter your payment information. This helps ensure
that anyone making a donation to the Make-A-Wish Foundation has the card in his
or her possession and is not using a stolen credit card number.
FOR VISA, MASTERCARD AND DISCOVER CARDS
Turn the card over and look at the signature box. You will find either the
entire 16-digit credit card number or just the last 4 digits, followed by the
3-digit CSC.
FOR AMERICAN EXPRESS CARDS
The CSC is always located above the account number on the face of the card,
sometimes on the left side and sometimes on the right. Note: Some American
Express cards have a 4-digit number below the account number. This is not the
CSC.
BANK ACCOUNT INFORMATION
Your bank information can be found on your check at the bottom. It will look
similar to the following:
Transaction Processing
MAKE IT MONTHLY
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kids?
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No thanks, I prefer to make a single gift of
MAKE IT MONTHLY
Would you consider a monthly gift of instead to support granting wishes for
kids?
Yes, I'll make a monthly gift of
No thanks, I prefer to make a single gift of
WILL YOU CONSIDER SENDING AN E-CARD?
To ensure every dollar of your donation goes to helping grant more wishes,
processing times for paper cards may be delayed up to 6 weeks. Sending an ecard
will notify your recipient today.
Yes, I'll send an e-card instead I prefer to send a physical card
Donate by Mail
If you prefer to mail in your donation, please download and complete the mail-in
form available below and send your donation with a personal check, money order
or credit card information to the address noted on the form.
Download form
Managing Our Funds
Make-A-Wish America is proud of the way it manages and safeguards the generous
contributions from individual donors, corporations and other organizations.
Learn how funds are used
©2006-2024 Make-A-Wish Foundation of America
Make-A-Wish Foundation of America is an Arizona nonprofit corporation exempt
from federal income tax under Section 501(c)(3) of the Internal Revenue Code.
Federal Identification Number (EIN): 86-0481941 Privacy Policy & Terms | FAQ
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