events.childrens-specialized.org
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URL:
https://events.childrens-specialized.org/index.cfm?fuseaction=donate.event&eventID=503
Submission: On January 30 via api from US — Scanned from DE
Submission: On January 30 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: donate — POST index.cfm?
<form name="donate" id="donate" class="form-horizontal js-payment-form" action="index.cfm?" method="post" novalidate="novalidate">
<input type="hidden" name="donationData" id="donation-data">
<input type="hidden" name="recurring" id="recurring" value="0">
<input type="hidden" name="fulfillmentNoteExists" value="0">
<input type="hidden" name="formSubmit" value="1">
<input type="hidden" name="fuseaction" id="fuseaction" value="donate.ajaxConfirmValidate">
<h2>Supporting Children's Specialized Hospital Foundation</h2>
<div class="dd-u-mb-40">
<legend>Your Donation</legend>
<input id="currencysymbol" name="currencySymbol" type="hidden" value="$">
<input name="suggestedDonationID" type="hidden" value="D8AFB712-D2EB-B0F3-9DFE31DCAE916104">
<div class="control-group js-donation-option">
<label class="control-label" for="donationOption"><strong class="required" aria-required="true">Donation Option<span>*</span></strong></label>
<div class="controls">
<div class="dd-c-tabs-donation-options">
<label class="js-one-time">
<input class="dd-u-sr-only" name="donationOption" type="radio" value="">
<strong> One-Time </strong>
</label>
<label class="js-recurring-monthly">
<input class="dd-u-sr-only" name="donationOption" type="radio" value="monthly">
<strong> Monthly </strong>
<div class="js-recurring-monthly" style="display:none;">
<span style="font-size: 20px; color: #888">per month</span>
</div>
</label>
<label class="js-recurring-annual">
<input class="dd-u-sr-only" name="donationOption" type="radio" value="annual">
<strong> Yearly </strong>
</label>
<div class="js-recurring-annual" style="display:none;">
<span style="font-size: 20px; color: #888">per year</span>
</div>
</div>
</div>
</div>
<input id="currency" name="currency" type="hidden" value="USD">
<input type="hidden" name="incentiveID" value="">
<input type="hidden" name="fulfillmentNote" value="">
<div class="control-group js-choose-an-incentive-target js-recurring-input-target">
<fieldset class="control-group dd-c-fieldset js-sda-fieldset suggested-donation-option-group" style="">
<legend class="control-label dd-c-legend dd-v-legend-fieldset js-fieldset-legend">
<strong class="required" aria-required="true">Donation Amount<span>*</span></strong>
</legend>
<div class="controls js-sda-controls">
<div class="row-fluid js-option-container js-option-single" style="">
<div class="span8 js-donation-options dd-sda-option-simple-group" style="float: none;"><span class="js-option-simple dd-sda-option-simple">
<button type="button" class="dd-btn js-option js-option-title js-field-radio-input js-option-title-single-D8AB0E50-E9CF-B6BF-3693D3AC2C49ED30 inactive">$25.00</button>
</span><span class="js-option-simple dd-sda-option-simple">
<button type="button" class="dd-btn js-option js-option-title js-field-radio-input js-option-title-single-D8AFB712-D2EB-B0F3-9DFE31DCAE916104 js-option-default active">$50.00</button>
</span><span class="js-option-simple dd-sda-option-simple">
<button type="button" class="dd-btn js-option js-option-title js-field-radio-input js-option-title-single-D8B20072-ABB4-EA12-18730392197D7980 inactive">$100.00</button>
</span><span class="js-option-simple dd-sda-option-simple">
<button type="button" class="dd-btn js-option js-option-title js-field-radio-input js-option-title-single-D8B425B6-FA08-826D-63A865A98FD85FC9 inactive">$250.00</button>
</span><span class="js-option-simple dd-sda-option-simple">
<button type="button" class="dd-btn js-option js-option-title js-field-radio-input js-option-title-single-D8B6369A-CA14-990D-4E529DB27623FDC3 inactive">$500.00</button>
</span><span class="js-option-simple dd-sda-option-simple">
<button type="button" class="dd-btn js-option js-option-title js-field-radio-input js-option-title-single-1347F4B3-03F8-21C6-FAFA552EDBB9BC57 js-option-other inactive">Other</button>
</span></div>
</div>
<div class="row-fluid js-option-container js-option-annual" style="display: none;">
<div class="span8 js-donation-options dd-sda-option-simple-group" style="float: none;"><span class="js-option-simple dd-sda-option-simple">
<button type="button" class="dd-btn js-option js-option-title js-field-radio-input js-option-title-annual-D8AB0E50-E9CF-B6BF-3693D3AC2C49ED30 inactive">$25.00</button>
</span><span class="js-option-simple dd-sda-option-simple">
<button type="button" class="dd-btn js-option js-option-title js-field-radio-input js-option-title-annual-D8AFB712-D2EB-B0F3-9DFE31DCAE916104 js-option-default inactive">$50.00</button>
</span><span class="js-option-simple dd-sda-option-simple">
<button type="button" class="dd-btn js-option js-option-title js-field-radio-input js-option-title-annual-D8B20072-ABB4-EA12-18730392197D7980 inactive">$100.00</button>
</span><span class="js-option-simple dd-sda-option-simple">
<button type="button" class="dd-btn js-option js-option-title js-field-radio-input js-option-title-annual-D8B425B6-FA08-826D-63A865A98FD85FC9 inactive">$250.00</button>
</span><span class="js-option-simple dd-sda-option-simple">
<button type="button" class="dd-btn js-option js-option-title js-field-radio-input js-option-title-annual-D8B6369A-CA14-990D-4E529DB27623FDC3 inactive">$500.00</button>
</span><span class="js-option-simple dd-sda-option-simple">
<button type="button" class="dd-btn js-option js-option-title js-field-radio-input js-option-title-annual-1347F4B3-03F8-21C6-FAFA552EDBB9BC57 js-option-other inactive">Other</button>
</span></div>
</div>
<div class="row-fluid js-option-container js-option-monthly" style="display: none;">
<div class="span8 js-donation-options dd-sda-option-simple-group" style="float: none;"><span class="js-option-simple dd-sda-option-simple">
<button type="button" class="dd-btn js-option js-option-title js-field-radio-input js-option-title-monthly-D8AB0E50-E9CF-B6BF-3693D3AC2C49ED30 inactive">$25.00</button>
</span><span class="js-option-simple dd-sda-option-simple">
<button type="button" class="dd-btn js-option js-option-title js-field-radio-input js-option-title-monthly-D8AFB712-D2EB-B0F3-9DFE31DCAE916104 js-option-default inactive">$50.00</button>
</span><span class="js-option-simple dd-sda-option-simple">
<button type="button" class="dd-btn js-option js-option-title js-field-radio-input js-option-title-monthly-D8B20072-ABB4-EA12-18730392197D7980 inactive">$100.00</button>
</span><span class="js-option-simple dd-sda-option-simple">
<button type="button" class="dd-btn js-option js-option-title js-field-radio-input js-option-title-monthly-D8B425B6-FA08-826D-63A865A98FD85FC9 inactive">$250.00</button>
</span><span class="js-option-simple dd-sda-option-simple">
<button type="button" class="dd-btn js-option js-option-title js-field-radio-input js-option-title-monthly-D8B6369A-CA14-990D-4E529DB27623FDC3 inactive">$500.00</button>
</span><span class="js-option-simple dd-sda-option-simple">
<button type="button" class="dd-btn js-option js-option-title js-field-radio-input js-option-title-monthly-1347F4B3-03F8-21C6-FAFA552EDBB9BC57 js-option-other inactive">Other</button>
</span></div>
</div>
</div>
</fieldset>
<div class="control-group js-amount-field js-recurring-check-target js-processing-fee-check-target" style="display: none;">
<label class="control-label" for="donation-amount-input"><strong class="required" aria-required="true">Other Amount<span>*</span></strong></label>
<div class="controls">
<div class="js-amount-div post input-big" data-activity-label="Pledge Amount per " data-annual-label="Donation Amount per Year" data-monthly-label="Donation Amount per Month" data-other-label="Other Amount"
data-standard-label="Donation Amount">
<div class="js-amount-input pre dollar-large clearfix">
<div class="span8 input-append" style="position:relative; display: flex">
<span class="addon js-currency-symbol">$</span>
<input autocomplete="new-password" id="donation-amount-input" inputmode="decimal" name="donationAmountInput" pattern="[0-9]*" style="width: 100%;" type="text" value="0.00" aria-required="true" aria-invalid="false">
<span class="addon js-activity-pledge-unit-amount" style="display: none; right: 15px; text-transform: lowercase;">/</span>
</div>
</div>
</div>
</div>
</div>
<div class="controls">
<input id="donation-amount-hidden-input" name="donationAmount" type="hidden" value="50.00" aria-required="true" aria-invalid="false">
</div>
</div>
<div class="control-group js-activity-pledge-max-amount js-processing-fee-check-target js-choose-an-incentive-target" style="display: none;">
<label class="control-label" for="activity-pledge-max-amount"><strong>Maximum Amount to Donate (Optional)</strong></label>
<div class="controls">
<div class="row-fluid">
<div class="pre post span8 input-big">
<span class="addon js-currency-symbol">$</span>
<input type="text" placeholder="0" name="activityPledgeMaxAmount" id="activity-pledge-max-amount" class="span12 no-ms-clear" pattern="[0-9]*" inputmode="decimal" autocomplete="new-password">
<span class="addon" style="right: 15px">Total</span>
</div>
</div>
</div>
</div>
<div class="control-group js-processing-fee-check">
<div class="controls">
<label class="checkbox" style="padding-top: 0;">
<input type="checkbox" name="coverProcessingFee" value="1"> Yes! I’d like to cover processing costs. (<span class="js-processing-fee-amount">$1.50</span><span class="js-processing-fee-recurring-monthly" style="display: none;"> per
month</span><span class="js-processing-fee-recurring-annual" style="display: none;"> per year</span><span class="js-processing-fee-activity-pledge" style="display: none;"> per </span>) </label>
</div>
</div>
<div class="js-form-questions">
<input type="hidden" name="formID" value="DA7508B3-D776-2A32-F9749D3DDBEF9BE2">
<fieldset class="control-group question" data-admin-css="is_this_gift_anonymous_" data-display-question-option-id="" data-question-type="text" aria-hidden="false">
<label class="control-label dd-u-font-700" for="formquestionnote1"> Is this gift anonymous? </label>
<input type="hidden" name="formQuestionID1" value="81BAD5EF-D5CB-B474-41A378ACF7B50B8D">
<div class="controls">
<input type="hidden" name="formQuestionOptionID1" value="81BADDEA-AD3E-DFCE-E2CDAD30D10FE894">
<input type="text" maxlength="100" name="formQuestionNote1" id="formquestionnote1" data-question="is_this_gift_anonymous_" value="">
</div>
</fieldset>
<fieldset class="control-group question" data-admin-css="designation" data-display-question-option-id="" data-question-type="select" aria-hidden="false">
<label class="control-label dd-u-font-700" for="formquestionoptionid2"> Designation: </label>
<input type="hidden" name="formQuestionID2" value="1669F79E-94EF-9F56-A3E68851A002B91F">
<div class="controls">
<select data-question="designation" id="formquestionoptionid2" name="formQuestionOptionID2">
<option value="">[Select...]</option>
<option data-option="designationunrestricted" value="1669F79F-D63A-106C-63F4181F91C9F35D" selected="selected">Where the Need is Greatest</option>
<option data-option="designationnb" value="167C73F5-B53A-53D7-97A3BE9E75326D7F">New Brunswick Inpatient Hospital</option>
<option data-option="designationmtnltc" value="167C7496-EA9D-97CF-42E8256EFCE8BDB9">Long Term Care</option>
<option data-option="designationother" value="167C75AE-DAB4-78F7-E7B8A2F1211D2D7E">Other</option>
</select>
</div>
</fieldset>
<fieldset class="control-group question" data-admin-css="designationother" data-display-question-option-id="" data-question-type="textarea" aria-hidden="false">
<label class="control-label dd-u-font-700" for="formquestionnote3"> Other: </label>
<input type="hidden" name="formQuestionID3" value="167D493C-C4ED-3D4B-303B7AB1701E3734">
<div class="controls">
<input type="hidden" name="formQuestionOptionID3" value="167D493D-DFA2-FEC0-C9037DBCB019EEF8">
<textarea name="formQuestionNote3" id="formquestionnote3" data-question="designationother"></textarea>
</div>
</fieldset>
<fieldset class="control-group question" data-admin-css="honorormemorial" data-display-question-option-id="" data-question-type="radio" aria-hidden="false">
<legend class="control-label dd-c-legend"> Is this an Honor or Memorial gift? </legend>
<input type="hidden" name="formQuestionID4" value="DAAB2E0E-B37C-8F6C-DFB9FE3AE4CD0259">
<div class="controls">
<label class="radio">
<input type="radio" name="formQuestionOptionID4" id="formquestionoptionid4_1" value="DAAB2E0F-E50E-1890-005969490D87AFA4" data-question="honorormemorial" data-option="tributeyes"> Yes </label>
<label class="radio">
<input type="radio" name="formQuestionOptionID4" id="formquestionoptionid4_2" value="DB2F2D3B-EE62-BFDB-C80D08DC221A88F8" data-question="honorormemorial" data-option="tributeno"> No </label>
</div>
</fieldset>
<fieldset class="control-group question" data-admin-css="tributetype" data-display-question-option-id="" data-question-type="select" aria-hidden="false">
<label class="control-label dd-u-font-700" for="formquestionoptionid5"> Is yes, select the tribute type: </label>
<input type="hidden" name="formQuestionID5" value="13D3FE0D-A27D-BC1C-A55AFD090CFD018F">
<div class="controls">
<select data-question="tributetype" id="formquestionoptionid5" name="formQuestionOptionID5">
<option value="">[Select...]</option>
<option data-option="tributehonor" value="13D3FE0E-C500-3BFA-340AB2953D236BB7">Honor</option>
<option data-option="tributememorial" value="13DE4FAA-D1E4-17B6-F08FD00E31191442">Memorial</option>
</select>
</div>
</fieldset>
<fieldset class="control-group question" data-admin-css="tribute_occasion" data-display-question-option-id="" data-question-type="select" aria-hidden="false">
<label class="control-label dd-u-font-700" for="formquestionoptionid6"> Are you celebrating an occasion? </label>
<input type="hidden" name="formQuestionID6" value="581E1573-F8E9-AE5C-81312FF8B7111B9E">
<div class="controls">
<select data-question="tribute_occasion" id="formquestionoptionid6" name="formQuestionOptionID6">
<option value="">[Select...]</option>
<option data-option="holidays_tribute" value="B9E34749-A7B0-218F-4C980437D4EAE4FF">Holidays</option>
<option data-option="birthday" value="58A353E2-0F58-83BA-D97E3933DED98B35">Birthday</option>
<option data-option="engagement_wedding" value="58A3560B-E1D9-36C7-37EB0BA146AE7A43">Engagement or Wedding</option>
<option data-option="graduation" value="58A357B1-97CD-FBBE-8F82AA2022AEA7C6">Graduation</option>
<option data-option="birth" value="58A359C9-F08B-1EAF-537FD7799A0E0F2D">Birth</option>
<option data-option="anniversary_occasion" value="58A35C01-EAC2-32E3-EB83AF74107E24BB">Anniversary or Special Occasion</option>
<option data-option="other_tribute" value="58A35DA5-F199-C702-051D8322842BCE30">Other</option>
</select>
</div>
</fieldset>
<fieldset class="control-group question" data-admin-css="personal_message_to_tribu" data-display-question-option-id="" data-question-type="text" aria-hidden="false">
<label class="control-label dd-u-font-700" for="formquestionnote7"> Personal Message to Tribute (300 characters): </label>
<input type="hidden" name="formQuestionID7" value="58D9F3B0-F101-F97D-1490A2D053FFEFB6">
<div class="controls">
<input type="hidden" name="formQuestionOptionID7" value="58DA0FAC-C2BB-67A1-01189054A0052CDE">
<input type="text" maxlength="400" name="formQuestionNote7" id="formquestionnote7" data-question="personal_message_to_tribu" value="">
</div>
</fieldset>
<fieldset class="control-group question" data-admin-css="tributename" data-display-question-option-id="" data-question-type="text" aria-hidden="false">
<label class="control-label dd-u-font-700" for="formquestionnote8"> Tribute's Full Name </label>
<input type="hidden" name="formQuestionID8" value="DB40475A-AA3A-65D8-CFF31EFD74FA2A66">
<div class="controls">
<input type="hidden" name="formQuestionOptionID8" value="DB40475B-E87D-1631-4878BED7952D8F3B">
<input type="text" maxlength="150" name="formQuestionNote8" id="formquestionnote8" data-question="tributename" value="">
</div>
</fieldset>
<fieldset class="control-group question" data-admin-css="tributestreet" data-display-question-option-id="" data-question-type="text" aria-hidden="false">
<label class="control-label dd-u-font-700" for="formquestionnote9"> Tribute's Street Address </label>
<input type="hidden" name="formQuestionID9" value="0C8A9435-D511-048D-8F51131AC5B097A4">
<div class="controls">
<input type="hidden" name="formQuestionOptionID9" value="0C8A9436-FBD0-2E6D-ACC245AE79774706">
<input type="text" maxlength="150" name="formQuestionNote9" id="formquestionnote9" data-question="tributestreet" value="">
</div>
</fieldset>
<fieldset class="control-group question" data-admin-css="tributecity" data-display-question-option-id="" data-question-type="text" aria-hidden="false">
<label class="control-label dd-u-font-700" for="formquestionnote10"> Tribute's City </label>
<input type="hidden" name="formQuestionID10" value="0C944583-A2CD-107F-7B472FFC90DEA9AE">
<div class="controls">
<input type="hidden" name="formQuestionOptionID10" value="0C944584-95E6-7EA4-5A3573C975441BB2">
<input type="text" maxlength="150" name="formQuestionNote10" id="formquestionnote10" data-question="tributecity" value="">
</div>
</fieldset>
<fieldset class="control-group question" data-admin-css="tributestate" data-display-question-option-id="" data-question-type="text" aria-hidden="false">
<label class="control-label dd-u-font-700" for="formquestionnote11"> Tribute's State </label>
<input type="hidden" name="formQuestionID11" value="0C9AE72A-DA39-752C-22F8D87E88E7A6FD">
<div class="controls">
<input type="hidden" name="formQuestionOptionID11" value="0C9AE72B-98F5-00CA-75C631DBB364AC7E">
<input type="text" maxlength="100" name="formQuestionNote11" id="formquestionnote11" data-question="tributestate" value="">
</div>
</fieldset>
<fieldset class="control-group question" data-admin-css="tributezip" data-display-question-option-id="" data-question-type="text" aria-hidden="false">
<label class="control-label dd-u-font-700" for="formquestionnote12"> Tribute's Zip Code </label>
<input type="hidden" name="formQuestionID12" value="0CA2C450-BEDB-C9CB-5FC20912D23096A3">
<div class="controls">
<input type="hidden" name="formQuestionOptionID12" value="0CA2C451-E7E0-87E5-D366E784525D60ED">
<input type="text" aria-describedby="formquestionnote12-helper" maxlength="100" class="input-regex" name="formQuestionNote12" id="formquestionnote12" data-question="tributezip" value="">
<em class="help-block" id="formquestionnote12-helper"> (ex: 12345, 12345-1234) </em>
</div>
</fieldset>
</div>
<fieldset class="control-group dd-matching-gifts dd-u-mb-0">
<legend class="control-label legend-label" style="margin-top: 0;">Corporate Giving</legend>
<div class="controls">
<label class="radio">
<input checked="" name="giftType" type="radio" value="matchingGift">
<strong>Individual Gift</strong>
</label>
<label class="radio">
<input name="giftType" type="radio" value="behalfOfCompany">
<strong>Gift on behalf of my company</strong>
</label>
</div>
<div class="control-group dd-u-mb-0 dd-u-mt-10">
<div class="controls">
<div id="employer-matching" style="">
<label for="matching-employer">Employer Name</label>
<input class="span8" type="text" name="matchingEmployer" id="matching-employer" maxlength="80" autocomplete="new-password">
</div>
<div class="new-user" id="company-name-div" style="display:none;">
<label for="company-name">Company Name</label>
<input class="span8" type="text" name="companyName" id="company-name" maxlength="80" autocomplete="new-password">
</div>
</div>
</div>
</fieldset>
</div>
<fieldset class="dd-u-mb-40">
<legend>Payment</legend>
<div class="control-group js-payment-type payment-options-group dd-u-mb-0">
<label class="control-label" for=""><strong class="required" aria-required="true">Payment Method<span>*</span></strong></label>
<div class="controls">
<label aria-label="Apple Pay" class="radio payment-type-option" style="display: none;" data-payment-type="APPLEPAY">
<input type="radio" name="paymentType" value="APPLEPAY" disabled="">
<img alt="Apple Pay" class="paymenttype" src="https://donordrivecontent.com/resources/img/apple-pay-mark.svg?v=202401291124">
</label>
<label aria-label="Credit Card" class="radio payment-type-option js-currency-usd" style="" data-payment-type="CC">
<input type="radio" name="paymentType" value="CC">
<span class="payment-type-option-icon" data-payment-state="new">
<img alt="Credit Card" class="paymenttype" src="https://donordrivecontent.com/resources/img/cc_gen.svg?v=202401291124"> <img style="display: none" alt="Visa" class="paymenttype visa"
src="https://donordrivecontent.com/resources/img/cc_visa.svg?v=202401291124"> <img style="display: none" alt="Mastercard" class="paymenttype mc" src="https://donordrivecontent.com/resources/img/cc_mc.svg?v=202401291124"> <img
style="display: none" alt="American Express" class="paymenttype amex" src="https://donordrivecontent.com/resources/img/cc_amex.svg?v=202401291124"> <img style="display: none" alt="Discover" class="paymenttype discover"
src="https://donordrivecontent.com/resources/img/cc_discover.svg?v=202401291124">
</span>
</label>
<label aria-label="PayPal" class="radio payment-type-option js-currency-usd" style="" data-payment-type="PAYPAL">
<input type="radio" name="paymentType" value="PAYPAL">
<img alt="PayPal" class="paymenttype" src="https://donordrivecontent.com/resources/img/paypal.svg?v=202401291124">
</label>
<label aria-label="Bank Account" class="radio payment-type-option" style="display: none;" data-payment-type="ACH">
<input type="radio" name="paymentType" value="ACH" disabled="">
<span class="payment-type-option-icon" data-payment-state="new">
<img alt="Bank Account" id="ach" class="paymenttype" src="https://donordrivecontent.com/resources/img/bank-account-en.svg?v=202401291124">
</span>
</label>
<label aria-label="Amazon Pay" class="radio payment-type-option" style="display: none;" data-payment-type="AMAZONPAY">
<input type="radio" name="paymentType" value="AMAZONPAY" disabled="">
<img alt="Amazon Pay" class="paymenttype" src="https://donordrivecontent.com/resources/img/amazon-pay.svg?v=202401291124">
</label>
<label aria-label="Venmo" class="radio payment-type-option" style="display: none;" data-payment-type="VENMO">
<input type="radio" name="paymentType" value="VENMO" disabled="">
<img alt="Venmo" class="paymenttype" src="https://donordrivecontent.com/resources/img/blue_venmo_acceptance_mark.svg?v=202401291124">
</label>
<div class="payment-type-pod js-saved-payments" data-payment-state="saved" style="display: none;">
<label aria-label="Saved Bank Account" class="payment-saved js-saved-ach" style="display: none;" data-payment-type="ACH">
<input type="radio" name="savedPaymentType" value="ACH" class="pull-left" disabled="">
<img alt="Saved Bank Account" class="pull-left paymenttype" src="https://donordrivecontent.com/resources/img/bank-account-en.svg?v=202401291124">
<div class="payment-saved-details">
<span class="js-saved-name"></span>
<span class="js-saved-institution"><br><span class="js-saved-institution-name"></span></span>
<br>
<span class="js-saved-summary">{accountType} ending in {accountLastFour}</span>
</div>
<div class="clr"></div>
<div class="option-check">
<i class="icon-ok" aria-hidden="true" style="margin: 10px 0 0 0;"></i>
</div>
</label>
<label aria-label="Saved Credit Card" class="payment-saved js-saved-cc js-currency-usd" style="" data-payment-type="CC">
<input type="radio" name="savedPaymentType" value="CC" class="pull-left">
<img src="data:image/gif;base64,R0lGODlhAQABAAD/ACwAAAAAAQABAAACADs=" alt="Saved Card" class="pull-left paymenttype">
<div class="pull-left">
<span class="js-saved-name"></span>
<span class="js-saved-institution"><br><span class="js-saved-institution-name"></span></span>
<br>
<span class="js-saved-summary">{accountType} ending in {accountLastFour}</span>
</div>
<div class="clr"></div>
<div class="option-check">
<i class="icon-ok" aria-hidden="true" style="margin: 10px 0 0 0;"></i>
</div>
</label>
<div class="clr"></div>
<a href="#" class="js-saved-discard">Choose a different way to pay</a>
</div>
</div>
</div>
</fieldset>
<fieldset class="contact-fieldset dd-u-mb-40">
<legend>Contact Details</legend>
<div class="beenherebefore" id="welcome-back" style="display:none;">
<i class="icon-ok" aria-hidden="true"></i> <strong id="welcome-back-msg"></strong>
</div>
<div class="inline-login" id="beenhereblock">
<span class="icon-stack">
<i class="icon-circle icon-stack-base"></i>
<i class="icon-user icon icon-light" aria-hidden="true"></i>
</span>
<h1>Been here before?</h1>
<p>
<a href="#" class="forgotpasswordhide beenhereloginshow">Login to your account</a> to prefill the fields below with your information.
</p>
<div id="beenherelogin" style="display: none;">
<div class="row-fluid">
<div class="span6">
<label for="emaillogin">
<strong class="required" aria-required="true">Email Address<span>*</span></strong>
<input type="email" name="emaillogin" id="emaillogin" maxlength="60">
</label>
</div>
<div class="span6">
<label for="passwordlogin">
<strong class="required" aria-required="true">Password<span>*</span></strong>
<input type="password" name="passwordlogin" id="passwordlogin" maxlength="60" autocomplete="new-password">
</label>
</div>
</div>
<br>
<div id="formbtns" class="row-fluid">
<div class="span6">
<input class="btn-form inline-login-submit" type="button" value="Login">
<span class="hidden-mobile"> </span>
<a href="#" class="cancel beenhereloginhide">Cancel</a>
</div>
<div class="span6">
<a href="#" class="beenhereloginhide forgotpasswordshow">Forgot Password?</a>
</div>
</div>
</div>
<div id="forgotpasswordbox" style="display: none;">
<div class="row-fluid">
<div class="span6">
<label for="emailpassword">
<strong class="required" aria-required="true">Email Address<span>*</span></strong>
<input type="email" name="emailpassword" id="emailpassword" maxlength="60">
</label>
</div>
</div>
<br>
<div class="row-fluid">
<div class="span6">
<span id="sendpasswordbtns">
<input class="btn-form inline-login-forgot-password" type="button" value="Reset My Password">
<span class="hidden-mobile"> </span>
<a href="#" class="cancel forgotpasswordhide beenherelogintoggle">Cancel</a>
</span>
</div>
</div>
</div>
</div>
<fieldset class="dd-u-mb-0">
<div class="control-group" data-payment-field="accountName" style="margin-top: 0 !important;">
<label class="control-label"><strong class="required" aria-required="true">Name<span>*</span></strong></label>
<div class="controls new-user" id="constituent-name">
<div class="span8 js-name-fields">
<div class="inline-block" style="width: 48%;">
<label class="dd-u-sr-only" for="first-name"> First Name </label>
<input class="dd-u-w-full" type="text" name="firstName" id="first-name" maxlength="40" placeholder="First Name" autocomplete="given-name">
</div>
<div class="inline-block pull-right" style="width: 48%">
<label class="dd-u-sr-only" for="last-name"> Last Name </label>
<input class="dd-u-w-full" type="text" name="lastName" id="last-name" maxlength="60" placeholder="Last Name" autocomplete="family-name">
</div>
</div>
<div class="clr"></div>
</div>
</div>
</fieldset>
<div class="control-group js-display-name-container">
<label class="control-label" for="displayname"><strong>Show my name as (Optional)</strong></label>
<div class="controls">
<input type="text" class="span8" name="displayName" id="displayname" maxlength="101" placeholder="Ex: Grandma, The Smith Family">
</div>
</div>
<input type="hidden" name="isAnonymous" id="is-anonymous" value="0">
<div class="control-group" data-payment-field="email">
<label class="control-label" for="email">
<strong class="required" aria-required="true">Email Address<span>*</span></strong>
</label>
<div class="controls new-user" id="constituent-email">
<input class="span8 dd-u-mr-5" type="email" name="email" id="email" maxlength="60" autocomplete="email">
</div>
</div>
<div id="company-name-after-login" style="display:none;"></div>
<span class="new-user">
<input type="hidden" name="constituent_formID" value="CONSTITUENT">
<fieldset class="control-group question" data-admin-css="company" data-display-question-option-id="" data-question-type="text" aria-hidden="false">
<label class="control-label dd-u-font-700" for="constituent_formquestionnote2"> Company </label>
<input type="hidden" name="constituent_formQuestionID2" value="A315D4D2-ADD7-BE49-61D054A2EDF16516">
<div class="controls">
<input type="hidden" name="constituent_formQuestionOptionID2" value="A315D4D3-C8D1-C5D7-A2E7512958866037">
<input type="text" maxlength="100" name="constituent_formQuestionNote2" id="constituent_formquestionnote2" data-question="company" value="">
</div>
</fieldset>
<fieldset class="control-group question" data-admin-css="news" data-display-question-option-id="" data-question-type="checkbox" aria-hidden="false">
<legend class="control-label dd-c-legend"> Receive important news and updates from Children's Specialized Hospital Foundation </legend>
<input type="hidden" name="constituent_formQuestionID3" value="E76442C6-BDD0-D4EE-11CD5B3C96664B92">
<div class="controls">
<label class="checkbox">
<input type="checkbox" name="constituent_formQuestionOptionID3_1" id="constituent_formquestionoptionid3_1" value="E76445BB-F95A-6803-2A110BA9F449E875" data-hidden-name="constituent_formQuestionOptionID3" data-question="news"
data-option="yes" checked="checked"> Yes </label>
<input type="hidden" name="constituent_formQuestionOptionID3" value="E76445BB-F95A-6803-2A110BA9F449E875">
</div>
</fieldset>
</span>
</fieldset>
<div class="form-actions dd-u-my-0">
<span data-payment-submit="APPLEPAY" style="display: none;"></span>
<span data-payment-submit="CC" style=""><button type="button" class="dd-btn"><i class="icon-credit-card" aria-hidden="true"></i> Donate with Credit Card</button> </span>
<div data-payment-submit="PAYPAL" class="pp-btn" style="display: none;">
<div id="zoid-paypal-buttons-uid_37d37e7451_mty6mzc6ntq" class="paypal-buttons paypal-buttons-context-iframe paypal-buttons-label-checkout paypal-buttons-layout-horizontal" data-paypal-smart-button-version="5.0.421"
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<style nonce="">
#zoid-paypal-buttons-uid_37d37e7451_mty6mzc6ntq {
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display: inline-block;
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min-height: 25px;
min-width: 150px;
font-size: 0;
}
#zoid-paypal-buttons-uid_37d37e7451_mty6mzc6ntq>iframe {
position: absolute;
top: 0;
left: 0;
width: 100%;
height: 100%;
}
#zoid-paypal-buttons-uid_37d37e7451_mty6mzc6ntq>iframe.component-frame {
z-index: 100;
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#zoid-paypal-buttons-uid_37d37e7451_mty6mzc6ntq>iframe.prerender-frame {
transition: opacity .2s linear;
z-index: 200;
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#zoid-paypal-buttons-uid_37d37e7451_mty6mzc6ntq>iframe.visible {
opacity: 1;
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#zoid-paypal-buttons-uid_37d37e7451_mty6mzc6ntq>iframe.invisible {
opacity: 0;
pointer-events: none;
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#zoid-paypal-buttons-uid_37d37e7451_mty6mzc6ntq>.smart-menu {
position: absolute;
z-index: 300;
top: 0;
left: 0;
width: 100%;
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title="PayPal" allowpaymentrequest="allowpaymentrequest" scrolling="no" id="jsx-iframe-eb036a1418" class="component-frame visible" style="background-color: transparent; border: none;"></iframe>
<div id="smart-menu" class="smart-menu"></div>
<div id="installments-modal" class="installments-modal"></div><iframe name="__detect_close_uid_8a482650c9_mty6mzc6ntq__" style="display: none;"></iframe>
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<div data-payment-submit="AMAZONPAY" class="ap-btn" style="display: none;"><button type="button" style="width: 100%; display: block;" class="dd-btn"> Donate {amount}</button> </div>
<span data-payment-submit="ACH" style="display: none;"><button type="button" class="dd-btn"><svg style="margin-right: 8px; margin-left: 3px; position: relative; top: 1px" xmlns="http://www.w3.org/2000/svg" width="15" height="15"
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</svg>Donate with Bank Account</button> </span>
<span data-payment-submit="VENMO" class="venmo-btn" style="display: none;">
<button type="button" class="dd-btn"> Venmo</button>
<small class="text-center block" style="margin: 10px 0">Tapping this button will complete your donation of $50.00.</small>
</span>
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TOGETHER, WE CAN HELP ALL CHILDREN REACH THEIR FULL POTENTIAL.
Your donation will help support the over 35,000 children treated annually at
Children's Specialized Hospital facing special health challenges—from chronic
illnesses and complex physical disabilities like brain and spinal cord injuries,
to developmental and behavioral issues like autism and mental health.
100% of every donation supports the vital programs and services that are
transforming the lives of children with special healthcare needs. Your gift
ensures that children have access to the specialized health care he or she needs
to learn to walk, talk, eat and breathe independently—again, or for the first
time.
Thank you for your support!
SUPPORTING CHILDREN'S SPECIALIZED HOSPITAL FOUNDATION
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