secure.easterseals.com
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Submitted URL: https://secure.easterseals.com/site/R?i=9CL_aNjkESR2MuhunSn-Z65x0V2sCUMXEou11KbbBYMQ_ag6aEQsBQ
Effective URL: https://secure.easterseals.com/site/Donation2?idb=1007032688&df_id=21645&mfc_pref=T&21645.donation=form1&s_src=jtk1442-su-d&utm...
Submission: On November 07 via api from US — Scanned from CA
Effective URL: https://secure.easterseals.com/site/Donation2?idb=1007032688&df_id=21645&mfc_pref=T&21645.donation=form1&s_src=jtk1442-su-d&utm...
Submission: On November 07 via api from US — Scanned from CA
Form analysis 1 forms found in the DOM
Name: process — POST https://secure.easterseals.com/site/Donation2
<form name="process" id="ProcessForm" action="https://secure.easterseals.com/site/Donation2" method="post" onsubmit="return checkDoubleClick();">
<div class="donation-form-container responsive clearfix">
<script type="text/javascript">
<!--
function reloadPage() {
window.location.reload(true);
}
function testAjax() {
var xmlHttp = null;
// Opera 8.0+, Firefox, Chrome, Safari
try {
xmlHttp = new XMLHttpRequest();
} catch (e) {
// Internet Explorer Browsers
try {
xmlHttp = new ActiveXObject("Msxml2.XMLHTTP");
} catch (e) {
try {
xmlHttp = new ActiveXObject("Microsoft.XMLHTTP");
} catch (e) {
return false;
}
}
}
xmlHttp.open('POST', 'AjaxHelper;jsessionid=00000000.app20075a?NONCE_TOKEN=9DDDE52173F79DDB69E50585A5C14C6F', true);
xmlHttp.send();
}
addOnLoadHandler(testAjax);
//
-->
</script>
<div class="donation-form-content">
<input type="hidden" name="user_donation_amt" id="user_donation_amt" value="">
<input type="hidden" name="company_min_matching_amt" id="company_min_matching_amt" value="">
<input type="hidden" name="currency_locale" id="currency_locale" value="en_US">
<input type="hidden" name="cc_available" id="cc_available" value="false">
<input type="hidden" name="debit_available" id="debit_available" value="false">
<input type="hidden" name="paypal_available" id="paypal_available" value="false">
<input type="hidden" name="wallets_available" id="wallets_available" value="false">
<input type="hidden" name="primary_color" id="primary_color" value="">
<input type="hidden" name="secure_url" id="secure_url" value="https://secure.easterseals.com/site/">
<input type="hidden" name="is_admin_app" id="is_admin_app" value="F">
<input type="hidden" name="environment_id" id="environment_id" value="">
<input type="hidden" name="merchant_account_configuration_id" id="merchant_account_configuration_id" value="">
<input type="hidden" name="pco_javascript_location" id="pco_javascript_location" value="">
<input type="hidden" name="pco_language_locale" id="pco_language_locale" value="en_US">
<input type="hidden" name="pco_environment_zone" id="pco_environment_zone" value="p-usa01">
<div class="form-row">
<div class="html-caption-container">
<p class="donform_text1">Donate to Easterseals today!</p>
<p>We’re incredibly proud of the support we’re able to offer our nation’s veterans, especially when they have nowhere else to turn.</p>
<p>But whether it’s helping veterans access health care, employment, child care, or other specialized services we count on supporters like YOU to power our vital programs and services for veterans and military families.</p>
<p class="donform_text2"><strong>Make your gift today to help support our programs and services for veterans, military families, and all the people who benefit from Easterseals.</strong></p>
<style type="text/css">
<!--
div.donation-level-label-container,
#level_flexibleduration_row {
display: none !important;
}
.honmem-title {
display: none;
}
-->
</style>
</div>
</div>
<div id="level_flexible_row">
<div class="don-standard-levels form-row">
<div class="levels-label">
</div>
<div id="level_flexible_row" class="form-row form-donation-level">
<div class="form-content">
<span class="field-required"></span> <span class="aural-only">Field Is Required</span>
<span class="FormLabelText">
<h2 class="section-header-container">Select an Amount</h2>
</span>
<div class="donation-level-general-ask">
</div>
<div class="donation-levels">
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_flexibleexpanded" id="level_flexibleexpanded44117" value="44117" onclick="evalMatchingGift('$15.00');
updateDonorCoverAmount('$15.00');"><span class="don_radio_a" id="level_flexibleexpanded44117_a"><img class="don_checkbox_img" id="level_flexibleexpanded44117_img" data-radgroup="level_flexibleexpanded"
src="../bb/images/es2016_radio_button_unclick.png"></span>
</div>
<label for="level_flexibleexpanded44117" onclick="">
<div class="donation-level-amount-container">$15</div>
</label>
<input type="hidden" name="level_flexibleexpanded44117dynamicAmount" id="level_flexibleexpanded44117dynamicAmount" value="1500">
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_44117expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_flexibleexpanded" id="level_flexibleexpanded44105" value="44105" onclick="evalMatchingGift('$25.00');
updateDonorCoverAmount('$25.00');"><span class="don_radio_a" id="level_flexibleexpanded44105_a"><img class="don_checkbox_img" id="level_flexibleexpanded44105_img" data-radgroup="level_flexibleexpanded"
src="../bb/images/es2016_radio_button_unclick.png"></span>
</div>
<label for="level_flexibleexpanded44105" onclick="">
<div class="donation-level-amount-container">$25</div>
</label>
<input type="hidden" name="level_flexibleexpanded44105dynamicAmount" id="level_flexibleexpanded44105dynamicAmount" value="2500">
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_44105expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_flexibleexpanded" id="level_flexibleexpanded44119" value="44119" onclick="evalMatchingGift('$50.00');
updateDonorCoverAmount('$50.00');"><span class="don_radio_a" id="level_flexibleexpanded44119_a"><img class="don_checkbox_img" id="level_flexibleexpanded44119_img" data-radgroup="level_flexibleexpanded"
src="../bb/images/es2016_radio_button_unclick.png"></span>
</div>
<label for="level_flexibleexpanded44119" onclick="">
<div class="donation-level-amount-container">$50</div>
</label>
<input type="hidden" name="level_flexibleexpanded44119dynamicAmount" id="level_flexibleexpanded44119dynamicAmount" value="5000">
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_44119expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_flexibleexpanded" id="level_flexibleexpanded44115" value="44115" onclick="evalMatchingGift('$100.00');
updateDonorCoverAmount('$100.00');"><span class="don_radio_a" id="level_flexibleexpanded44115_a"><img class="don_checkbox_img" id="level_flexibleexpanded44115_img" data-radgroup="level_flexibleexpanded"
src="../bb/images/es2016_radio_button_unclick.png"></span>
</div>
<label for="level_flexibleexpanded44115" onclick="">
<div class="donation-level-amount-container">$100</div>
</label>
<input type="hidden" name="level_flexibleexpanded44115dynamicAmount" id="level_flexibleexpanded44115dynamicAmount" value="10000">
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_44115expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_flexibleexpanded" id="level_flexibleexpanded44111" value="44111" onclick="evalMatchingGift('$15.00');
updateDonorCoverAmount('$15.00');"><span class="don_radio_a" id="level_flexibleexpanded44111_a"><img class="don_checkbox_img" id="level_flexibleexpanded44111_img" data-radgroup="level_flexibleexpanded"
src="../bb/images/es2016_radio_button_unclick.png"></span>
</div>
<label for="level_flexibleexpanded44111" onclick="">
<div class="donation-level-amount-container">$15</div>
</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_44111expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_flexibleexpanded" id="level_flexibleexpanded44107" value="44107" onclick="evalMatchingGift('$25.00');
updateDonorCoverAmount('$25.00');"><span class="don_radio_a" id="level_flexibleexpanded44107_a"><img class="don_checkbox_img" id="level_flexibleexpanded44107_img" data-radgroup="level_flexibleexpanded"
src="../bb/images/es2016_radio_button_unclick.png"></span>
</div>
<label for="level_flexibleexpanded44107" onclick="">
<div class="donation-level-amount-container">$25</div>
</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_44107expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_flexibleexpanded" id="level_flexibleexpanded44113" value="44113" onclick="evalMatchingGift('$35.00');
updateDonorCoverAmount('$35.00');"><span class="don_radio_a" id="level_flexibleexpanded44113_a"><img class="don_checkbox_img" id="level_flexibleexpanded44113_img" data-radgroup="level_flexibleexpanded"
src="../bb/images/es2016_radio_button_unclick.png"></span>
</div>
<label for="level_flexibleexpanded44113" onclick="">
<div class="donation-level-amount-container">$35</div>
</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_44113expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_flexibleexpanded" id="level_flexibleexpanded44108" value="44108" onclick="evalMatchingGift('$50.00');
updateDonorCoverAmount('$50.00');"><span class="don_radio_a" id="level_flexibleexpanded44108_a"><img class="don_checkbox_img" id="level_flexibleexpanded44108_img" data-radgroup="level_flexibleexpanded"
src="../bb/images/es2016_radio_button_unclick.png"></span>
</div>
<label for="level_flexibleexpanded44108" onclick="">
<div class="donation-level-amount-container">$50</div>
</label>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_44108expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container checked">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_flexibleexpanded" id="level_flexibleexpanded44114" value="44114" checked="checked" onclick="evalMatchingGift(document.getElementById('level_flexibleexpanded44114amount').value);
updateDonorCoverAmount(document.getElementById('level_flexibleexpanded44114amount').value);"><span class="don_radio_a" id="level_flexibleexpanded44114_a"><img class="don_checkbox_img" id="level_flexibleexpanded44114_img"
data-radgroup="level_flexibleexpanded" src="../bb/images/es2016_radio_button_click.png"></span>
</div>
<div class="donation-level-user-entered">
<label for="level_flexibleexpanded44114amount"><span class="aural-only">Enter amount</span></label>
<input type="text" name="level_flexibleexpanded44114amount" id="level_flexibleexpanded44114amount" value="" size="12" maxlength="50"
onfocus="var el = document.getElementById ('level_flexibleexpanded44114');if (el) el.click(); fire_obs_comp_event('level_flexibleexpanded44114amount', this, event);evalMatchingGift(value); "
onchange="fire_obs_comp_event('level_flexibleexpanded44114amount', this, event);evalMatchingGift(value);" onkeyup="fire_obs_comp_event('level_flexibleexpanded44114amount', this, event);evalMatchingGift(value);"
onblur="fire_obs_comp_event('level_flexibleexpanded44114amount', this);updateDonorCoverAmount(value);" placeholder="Other">
<div id="minimum_amount_notice" style="display: none;">Minimum donation amount is $<span>5</span></div>
</div>
</div>
<input type="hidden" name="level_flexibleexpandedsubmit" id="level_flexible_44114expandedsubmit" value="true">
</div>
</div>
</div>
<div id="donlevelscont"></div>
</div>
<script type="text/javascript">
Y.use("jquery-ui", function(Y) {
jQuery(function() {
// subscribe observables
jQuery('div.donation-level-element-container').find('input[type="radio"]').each(function() {
var syncAction = function(obj) {
if (obj.is(':checked')) {
obj.closest('div.donation-level-container').addClass('selected');
} else {
obj.closest('div.donation-level-container').removeClass('selected');
};
return arguments.callee;
}(jQuery(this));
jQuery(this).click(function() {
jQuery('div.donation-level-container').removeClass('selected');
syncAction(jQuery(this));
});
});
});
});
</script><noscript> </noscript>
</div>
<div class="levels-gift-aid">
</div>
<input type="hidden" name="level_flexiblesubmit" id="level_flexiblesubmit" value="true">
<script type="text/javascript">
function updateDonorCoverAmount(gift) {
var amountHidden = document.getElementById('user_donation_amt');
if (amountHidden !== null) {
amountHidden.value = gift;
}
if (typeof updateAmount !== "undefined") {
updateAmount(gift);
}
};
function evalMatchingGift(gift) {}
</script><noscript> </noscript>
</div>
<div id="level_flexiblegift_type_Row" class="form-row field-required">
<div class="form-content">
<fieldset>
<legend> Gift type: </legend>
<div class="designated-giving-recurring-row">
<input type="radio" name="level_flexiblegift_type" id="level_flexiblegift_type1" value="1" checked="checked" onclick="fire_obs_comp_event('level_flexiblegift_type', this);"
onkeypress="fire_obs_comp_event('level_flexiblegift_type', this);"><span class="don_radio_a" id="level_flexiblegift_type1_a"><img class="don_checkbox_img" id="level_flexiblegift_type1_img" data-radgroup="level_flexiblegift_type"
src="../bb/images/es2016_radio_button_click.png"></span>
<label for="level_flexiblegift_type1">One-time gift</label>
</div>
<div class="designated-giving-recurring-row">
<input type="radio" name="level_flexiblegift_type" id="level_flexiblegift_type2" value="2" onclick="fire_obs_comp_event('level_flexiblegift_type', this);" onkeypress="fire_obs_comp_event('level_flexiblegift_type', this);"><span
class="don_radio_a" id="level_flexiblegift_type2_a"><img class="don_checkbox_img" id="level_flexiblegift_type2_img" data-radgroup="level_flexiblegift_type" src="../bb/images/es2016_radio_button_unclick.png"></span>
<label for="level_flexiblegift_type2">Monthly gift</label>
</div>
</fieldset>
</div>
<input type="hidden" name="level_flexiblegift_typesubmit" id="level_flexiblegift_typesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableRadioComponent('level_flexiblegift_type', 'name');
</script><noscript> </noscript>
<input type="hidden" name="recurring_options_name" id="recurring_options_name" value="level_flexiblegift_type">
</div>
<div id="level_flexibleduration_row" class="form-row form-selectlist" style="display: none;">
<div class="form-content">
<label class="FormLabel" for="level_flexibleduration">Select a Gift Duration:</label>
<select name="level_flexibleduration" id="level_flexibleduration" size="1" disabled="">
<option></option>
<optgroup label="Monthly">
<option value="M:0">Forever(Monthly)</option>
<option value="M:12">12 months</option>
</optgroup>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('level_flexibleduration', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('level_flexibleduration_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="level_flexibledurationsubmit_skip" id="level_flexibledurationsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('level_flexibleduration', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('level_flexibleduration_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('level_flexiblegift_type.2', new ComponentEnabler('level_flexibleduration'));
function level_flexibleduration_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('level_flexibleduration', src);
}
}
var el = document.getElementById('level_flexibleduration');
if (el) {
Utils.addEvent(el, 'change', level_flexibleduration_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<script type="text/javascript">
// subscribe listeners to make an ajax call to the server to calculate the total amount
Y.use('jquery-noconflict', function() {
var fetchAmountFunc = function() {
// find all the select, textarea, input, etc... and format them into key=val pairs.
var params = jQuery('#level_flexible_row :input').serialize();
// parse the path and append the key/value pairs above to the url
var url = 'https://secure.easterseals.com/site/Donation2?idb=1475501833&level_flexibleajaxfetch=true&df_id=21645&mfc_pref=T&21645.donation=form1&level_flexibletotalcalculateBtn=true';
var index = url.indexOf("?");
var path = url.substring(0, index);
var args = url.substring(index + 1, url.length);
args += '&' + params;
jQuery.ajax(path, {
data: args,
success: function(data) {
if (!data) {
data = '0.00';
}
jQuery('#level_flexible_row .donation-level-total-amount').html(data);
jQuery('#recurring_gift_terms_acceptance_message_container').trigger("recurringTermsChange");
}
});
};
jQuery('#level_flexible_row :input[type=text]').blur(function() {
fetchAmountFunc();
});
jQuery('#level_flexible_row input:checkbox, #level_flexible_row input:radio').click(function() {
fetchAmountFunc();
});
jQuery('#level_flexible_row select').change(function() {
fetchAmountFunc();
});
// call it on page load
fetchAmountFunc();
});
</script><noscript> </noscript>
</div>
<div class="form-row">
<div class="html-caption-container">
<script>
// Insert minimum amount notice
document.querySelector('.donation-level-user-entered input[type="text"]').insertAdjacentHTML('afterEnd', '<div id="minimum_amount_notice">Minimum donation amount is $<span>5</span></div>');
// Trim .00 from amounts
var donationAmount = document.getElementsByClassName('donation-level-amount-container');
for (var i = 0; i < donationAmount.length; i++) {
var fullAmount = donationAmount[i].innerText;
var shortened = fullAmount.slice(0, fullAmount.lastIndexOf('.'));
donationAmount[i].innerText = shortened;
}
// Format with decimal
var otherAmount = document.querySelector('.donation-level-user-entered input[type=text]');
otherAmount.value = otherAmount.value.replace('$', '');
if (otherAmount.value.indexOf('.00') > -1) {
otherAmount.value = otherAmount.value.replace('.00', '');
}
// Format select amount header
document.querySelector('.don-standard-levels .FormLabelText').innerHTML = '<h2 class="section-header-container">Select an Amount</h2>';
</script>
<style>
#monthly-giving-highlight span {
font-size: 16px;
color: #cf4b04;
font-style: italic;
display: flex;
padding-top: 10px;
padding-left: 3px;
}
#image-arrow-container {
float: left;
}
#level_flexiblegift_type_Row {
margin-bottom: -20px;
}
div.donation-levels div.donation-level-container:first-child+div.donation-level-container+div.donation-level-container+div.donation-level-container+div.donation-level-container,
div.donation-levels div.donation-level-container:first-child+div.donation-level-container+div.donation-level-container+div.donation-level-container+div.donation-level-container+div.donation-level-container,
div.donation-levels div.donation-level-container:first-child+div.donation-level-container+div.donation-level-container+div.donation-level-container+div.donation-level-container+div.donation-level-container+div.donation-level-container,
div.donation-levels div.donation-level-container:first-child+div.donation-level-container+div.donation-level-container+div.donation-level-container+div.donation-level-container+div.donation-level-container+div.donation-level-container+div.donation-level-container {
display: none;
}
</style>
<div id="monthly-giving-highlight">
<div id="image-arrow-container">
<img src="../images/content/pagebuilder/arrow-177-24.png">
</div>
<span>Giving a monthly donation is the best way to make an impact. You may cancel or change this monthly donation at any time.</span>
</div>
</div>
</div>
<div id="additional_amount_row" class="form-row form-text">
<div class="form-content">
<label for="additional_amountname">Additional Amount:</label>
<div class="form-input">
<input type="text" name="additional_amountname" id="additional_amountname" value="" maxlength="15" onchange="fire_obs_comp_event('additional_amount', this);">
</div>
</div>
<input type="hidden" name="additional_amountsubmit" id="additional_amountsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('additional_amount', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('additional_amount_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('additional_amountname')) {
document.getElementById('additional_amountname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('additional_amountname')) return document.getElementById('additional_amountname').checked;
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
</div>
<div id="tribute_show_honor_fields_row" class="form-row form-checkbox">
<div class="form-content">
<input type="checkbox" name="tribute_show_honor_fieldsname" id="tribute_show_honor_fieldsname" onclick="fire_obs_comp_event('tribute_show_honor_fields', this);">
<label for="tribute_show_honor_fieldsname">I would like to make this gift in honor or memory of someone special</label>
<input type="hidden" name="tribute_show_honor_fieldssubmit" id="tribute_show_honor_fieldssubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_show_honor_fields', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_show_honor_fields_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('tribute_show_honor_fieldsname')) {
document.getElementById('tribute_show_honor_fieldsname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('tribute_show_honor_fieldsname')) {
return document.getElementById('tribute_show_honor_fieldsname').checked;
}
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_type_row" class="form-row form-selectlist" style="display: none;">
<div class="form-content">
<label class="FormLabel" for="tribute_type">Honor Gift Type:</label>
<select name="tribute_type" id="tribute_type" size="1">
<option></option>
<option value="tribute_type_value1">In Memory of</option>
<option value="tribute_type_value2">In Honor of</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('tribute_type', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_type_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="tribute_typesubmit_skip" id="tribute_typesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_type', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_type_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_type'));
function tribute_type_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('tribute_type', src);
}
}
var el = document.getElementById('tribute_type');
if (el) {
Utils.addEvent(el, 'change', tribute_type_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="honoree_title_row" class="form-row form-selectlist" style="display: none;">
<div class="form-content">
<label class="FormLabel" for="honoree_title">Honoree Title:</label>
<select name="honoree_title" id="honoree_title" size="1">
<option></option>
<option value="Mr.">Mr.</option>
<option value="Ms.">Ms.</option>
<option value="Mrs.">Mrs.</option>
<option value="Miss">Miss</option>
<option value="Dr.">Dr.</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('honoree_title', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('honoree_title_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="honoree_titlesubmit_skip" id="honoree_titlesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('honoree_title', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('honoree_title_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('honoree_title'));
function honoree_title_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('honoree_title', src);
}
}
var el = document.getElementById('honoree_title');
if (el) {
Utils.addEvent(el, 'change', honoree_title_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_honoree_name_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_honoree_namename">Honoree Name:</label>
<input type="text" name="tribute_honoree_namename" id="tribute_honoree_namename" value="" maxlength="50">
<input type="hidden" name="tribute_honoree_namesubmit_skip" id="tribute_honoree_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_honoree_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_honoree_name_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_honoree_name'));
</script><noscript> </noscript>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<h2 class="section-header-container honmem-title">Notification Recipient Information</h2>
</div>
</div>
<div id="tribute_notify_recip_title_row" class="form-row form-selectlist" style="display: none;">
<div class="form-content">
<label class="FormLabel" for="tribute_notify_recip_title">Notification Recipient Title:</label>
<select name="tribute_notify_recip_title" id="tribute_notify_recip_title" size="1">
<option></option>
<option value="Mr.">Mr.</option>
<option value="Ms.">Ms.</option>
<option value="Mrs.">Mrs.</option>
<option value="Miss">Miss</option>
<option value="Dr.">Dr.</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('tribute_notify_recip_title', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_title_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="tribute_notify_recip_titlesubmit_skip" id="tribute_notify_recip_titlesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_title', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_title_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_title'));
function tribute_notify_recip_title_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('tribute_notify_recip_title', src);
}
}
var el = document.getElementById('tribute_notify_recip_title');
if (el) {
Utils.addEvent(el, 'change', tribute_notify_recip_title_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_name_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_notify_recip_namename">Notification Recipient Name:</label>
<input type="text" name="tribute_notify_recip_namename" id="tribute_notify_recip_namename" value="" maxlength="70">
<input type="hidden" name="tribute_notify_recip_namesubmit_skip" id="tribute_notify_recip_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_name_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_name'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_street1_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_notify_recip_street1name">Notification Recipient Street 1:</label>
<input type="text" name="tribute_notify_recip_street1name" id="tribute_notify_recip_street1name" value="" maxlength="50">
<input type="hidden" name="tribute_notify_recip_street1submit_skip" id="tribute_notify_recip_street1submit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_street1', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_street1_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_street1'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_street2_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<label for="tribute_notify_recip_street2name">Notification Recipient Street 2:</label>
<input type="text" name="tribute_notify_recip_street2name" id="tribute_notify_recip_street2name" value="" maxlength="50">
<input type="hidden" name="tribute_notify_recip_street2submit_skip" id="tribute_notify_recip_street2submit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_street2', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_street2_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_street2'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_city_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_notify_recip_cityname">Notification Recipient City:</label>
<input type="text" name="tribute_notify_recip_cityname" id="tribute_notify_recip_cityname" value="" maxlength="50">
<input type="hidden" name="tribute_notify_recip_citysubmit_skip" id="tribute_notify_recip_citysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_city', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_city_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_city'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_state_row" class="form-row form-selectlist" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label class="FormLabel" for="tribute_notify_recip_state">Notification Recipient State/Province:</label>
<select name="tribute_notify_recip_state" id="tribute_notify_recip_state" size="1" onchange="fire_obs_comp_event('tribute_notify_recip_state', this)">
<option></option>
<option value="AK">AK - Alaska</option>
<option value="AL">AL - Alabama</option>
<option value="AR">AR - Arkansas</option>
<option value="AZ">AZ - Arizona</option>
<option value="CA">CA - California</option>
<option value="CO">CO - Colorado</option>
<option value="CT">CT - Connecticut</option>
<option value="DC">DC - District of Columbia</option>
<option value="DE">DE - Delaware</option>
<option value="FL">FL - Florida</option>
<option value="GA">GA - Georgia</option>
<option value="HI">HI - Hawaii</option>
<option value="IA">IA - Iowa</option>
<option value="ID">ID - Idaho</option>
<option value="IL">IL - Illinois</option>
<option value="IN">IN - Indiana</option>
<option value="KS">KS - Kansas</option>
<option value="KY">KY - Kentucky</option>
<option value="LA">LA - Louisiana</option>
<option value="MA">MA - Massachusetts</option>
<option value="MD">MD - Maryland</option>
<option value="ME">ME - Maine</option>
<option value="MI">MI - Michigan</option>
<option value="MN">MN - Minnesota</option>
<option value="MO">MO - Missouri</option>
<option value="MS">MS - Mississippi</option>
<option value="MT">MT - Montana</option>
<option value="NC">NC - North Carolina</option>
<option value="ND">ND - North Dakota</option>
<option value="NE">NE - Nebraska</option>
<option value="NH">NH - New Hampshire</option>
<option value="NJ">NJ - New Jersey</option>
<option value="NM">NM - New Mexico</option>
<option value="NV">NV - Nevada</option>
<option value="NY">NY - New York</option>
<option value="OH">OH - Ohio</option>
<option value="OK">OK - Oklahoma</option>
<option value="OR">OR - Oregon</option>
<option value="PA">PA - Pennsylvania</option>
<option value="RI">RI - Rhode Island</option>
<option value="SC">SC - South Carolina</option>
<option value="SD">SD - South Dakota</option>
<option value="TN">TN - Tennessee</option>
<option value="TX">TX - Texas</option>
<option value="UT">UT - Utah</option>
<option value="VA">VA - Virginia</option>
<option value="VT">VT - Vermont</option>
<option value="WA">WA - Washington</option>
<option value="WI">WI - Wisconsin</option>
<option value="WV">WV - West Virginia</option>
<option value="WY">WY - Wyoming</option>
<option value="AS">AS - American Samoa</option>
<option value="FM">FM - Federated States of Micronesia</option>
<option value="GU">GU - Guam</option>
<option value="MH">MH - Marshall Islands</option>
<option value="MP">MP - Northern Mariana Islands</option>
<option value="PR">PR - Puerto Rico</option>
<option value="PW">PW - Palau</option>
<option value="VI">VI - Virgin Islands</option>
<option value="AA">AA - Armed Forces Americas</option>
<option value="AE">AE - Armed Forces</option>
<option value="AP">AP - Armed Forces Pacific</option>
<option value="AB">AB - Alberta</option>
<option value="BC">BC - British Columbia</option>
<option value="MB">MB - Manitoba</option>
<option value="NB">NB - New Brunswick</option>
<option value="NL">NL - Newfoundland and Labrador</option>
<option value="NS">NS - Nova Scotia</option>
<option value="NT">NT - Northwest Territories</option>
<option value="NU">NU - Nunavut</option>
<option value="ON">ON - Ontario</option>
<option value="PE">PE - Prince Edward Island</option>
<option value="QC">QC - Quebec</option>
<option value="SK">SK - Saskatchewan</option>
<option value="YT">YT - Yukon</option>
<option value="None">None</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('tribute_notify_recip_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_state_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="tribute_notify_recip_statesubmit_skip" id="tribute_notify_recip_statesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_state_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_state'));
function tribute_notify_recip_state_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('tribute_notify_recip_state', src);
}
}
var el = document.getElementById('tribute_notify_recip_state');
if (el) {
Utils.addEvent(el, 'change', tribute_notify_recip_state_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_zip_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_notify_recip_zipname">Notification Recipient ZIP Code:</label>
<input type="text" name="tribute_notify_recip_zipname" id="tribute_notify_recip_zipname" value="" maxlength="50">
<input type="hidden" name="tribute_notify_recip_zipsubmit_skip" id="tribute_notify_recip_zipsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_zip', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_zip_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_zip'));
</script><noscript> </noscript>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<h2 class="section-header-container honmem-title">Message to Notification Recipient</h2>
</div>
</div>
<div id="tribute_message_body_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_message_bodyname">Message Body:</label>
<textarea cols="50" rows="4" name="tribute_message_bodyname" id="tribute_message_bodyname"></textarea>
<input type="hidden" name="tribute_message_bodysubmit_skip" id="tribute_message_bodysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_message_body', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_message_body_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_message_body'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_message_closing_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_message_closingname">Message Closing:</label>
<input type="text" name="tribute_message_closingname" id="tribute_message_closingname" value="" maxlength="50">
<input type="hidden" name="tribute_message_closingsubmit_skip" id="tribute_message_closingsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_message_closing', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_message_closing_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_message_closing'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_signature_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_signaturename">Message Signature:</label>
<input type="text" name="tribute_signaturename" id="tribute_signaturename" value="" maxlength="70">
<input type="hidden" name="tribute_signaturesubmit_skip" id="tribute_signaturesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_signature', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_signature_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_signature'));
</script><noscript> </noscript>
</div>
</div>
<div id="message_include_gift_amount_row" class="form-row form-checkbox" style="display: none;">
<div class="form-content">
<input type="checkbox" name="message_include_gift_amountname" id="message_include_gift_amountname" onclick="fire_obs_comp_event('message_include_gift_amount', this);">
<label for="message_include_gift_amountname">Yes, include the gift amount in the message.</label>
<input type="hidden" name="message_include_gift_amountsubmit_skip" id="message_include_gift_amountsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('message_include_gift_amount', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('message_include_gift_amount_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('message_include_gift_amountname')) {
document.getElementById('message_include_gift_amountname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('message_include_gift_amountname')) {
return document.getElementById('message_include_gift_amountname').checked;
}
}
comp.clear = function() {
this.set(false);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('message_include_gift_amount'));
</script><noscript> </noscript>
</div>
</div>
<h2 class="section-header-container"> Billing Information </h2>
<div id="billing_first_name_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_first_namename">First Name:</label>
<input type="text" name="billing_first_namename" id="billing_first_namename" value="" maxlength="50">
<input type="hidden" name="billing_first_namesubmit" id="billing_first_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_first_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_first_name_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_last_name_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_last_namename">Last Name:</label>
<input type="text" name="billing_last_namename" id="billing_last_namename" value="" maxlength="50">
<input type="hidden" name="billing_last_namesubmit" id="billing_last_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_last_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_last_name_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_street1_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_addr_street1name">Street 1:</label>
<input type="text" name="billing_addr_street1name" id="billing_addr_street1name" value="" maxlength="50">
<input type="hidden" name="billing_addr_street1submit" id="billing_addr_street1submit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_street1', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_street1_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_street2_row" class="form-row form-text">
<div class="form-content">
<label for="billing_addr_street2name">Street 2:</label>
<input type="text" name="billing_addr_street2name" id="billing_addr_street2name" value="" maxlength="50">
<input type="hidden" name="billing_addr_street2submit" id="billing_addr_street2submit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_street2', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_street2_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_city_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_addr_cityname">City:</label>
<input type="text" name="billing_addr_cityname" id="billing_addr_cityname" value="" maxlength="50">
<input type="hidden" name="billing_addr_citysubmit" id="billing_addr_citysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_city', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_city_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_state_row" class="form-row form-selectlist">
<div class="form-content">
<span class="field-required"></span>
<label class="FormLabel" for="billing_addr_state">State/Province:</label>
<select name="billing_addr_state" id="billing_addr_state" size="1" onchange="fire_obs_comp_event('billing_addr_state', this)">
<option></option>
<option selected="selected" value="AK">AK - Alaska</option>
<option value="AL">AL - Alabama</option>
<option value="AR">AR - Arkansas</option>
<option value="AZ">AZ - Arizona</option>
<option value="CA">CA - California</option>
<option value="CO">CO - Colorado</option>
<option value="CT">CT - Connecticut</option>
<option value="DC">DC - District of Columbia</option>
<option value="DE">DE - Delaware</option>
<option value="FL">FL - Florida</option>
<option value="GA">GA - Georgia</option>
<option value="HI">HI - Hawaii</option>
<option value="IA">IA - Iowa</option>
<option value="ID">ID - Idaho</option>
<option value="IL">IL - Illinois</option>
<option value="IN">IN - Indiana</option>
<option value="KS">KS - Kansas</option>
<option value="KY">KY - Kentucky</option>
<option value="LA">LA - Louisiana</option>
<option value="MA">MA - Massachusetts</option>
<option value="MD">MD - Maryland</option>
<option value="ME">ME - Maine</option>
<option value="MI">MI - Michigan</option>
<option value="MN">MN - Minnesota</option>
<option value="MO">MO - Missouri</option>
<option value="MS">MS - Mississippi</option>
<option value="MT">MT - Montana</option>
<option value="NC">NC - North Carolina</option>
<option value="ND">ND - North Dakota</option>
<option value="NE">NE - Nebraska</option>
<option value="NH">NH - New Hampshire</option>
<option value="NJ">NJ - New Jersey</option>
<option value="NM">NM - New Mexico</option>
<option value="NV">NV - Nevada</option>
<option value="NY">NY - New York</option>
<option value="OH">OH - Ohio</option>
<option value="OK">OK - Oklahoma</option>
<option value="OR">OR - Oregon</option>
<option value="PA">PA - Pennsylvania</option>
<option value="RI">RI - Rhode Island</option>
<option value="SC">SC - South Carolina</option>
<option value="SD">SD - South Dakota</option>
<option value="TN">TN - Tennessee</option>
<option value="TX">TX - Texas</option>
<option value="UT">UT - Utah</option>
<option value="VA">VA - Virginia</option>
<option value="VT">VT - Vermont</option>
<option value="WA">WA - Washington</option>
<option value="WI">WI - Wisconsin</option>
<option value="WV">WV - West Virginia</option>
<option value="WY">WY - Wyoming</option>
<option value="AS">AS - American Samoa</option>
<option value="FM">FM - Federated States of Micronesia</option>
<option value="GU">GU - Guam</option>
<option value="MH">MH - Marshall Islands</option>
<option value="MP">MP - Northern Mariana Islands</option>
<option value="PR">PR - Puerto Rico</option>
<option value="PW">PW - Palau</option>
<option value="VI">VI - Virgin Islands</option>
<option value="AA">AA - Armed Forces Americas</option>
<option value="AE">AE - Armed Forces</option>
<option value="AP">AP - Armed Forces Pacific</option>
<option value="AB">AB - Alberta</option>
<option value="BC">BC - British Columbia</option>
<option value="MB">MB - Manitoba</option>
<option value="NB">NB - New Brunswick</option>
<option value="NL">NL - Newfoundland and Labrador</option>
<option value="NS">NS - Nova Scotia</option>
<option value="NT">NT - Northwest Territories</option>
<option value="NU">NU - Nunavut</option>
<option value="ON">ON - Ontario</option>
<option value="PE">PE - Prince Edward Island</option>
<option value="QC">QC - Quebec</option>
<option value="SK">SK - Saskatchewan</option>
<option value="YT">YT - Yukon</option>
<option value="None">None</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('billing_addr_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_state_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="billing_addr_statesubmit" id="billing_addr_statesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_state_row', _display);
this.disable_submit_flag(_hidden);
}
function billing_addr_state_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('billing_addr_state', src);
}
}
var el = document.getElementById('billing_addr_state');
if (el) {
Utils.addEvent(el, 'change', billing_addr_state_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_zip_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_addr_zipname">ZIP/Postal Code:</label>
<input type="text" name="billing_addr_zipname" id="billing_addr_zipname" value="" maxlength="50">
<input type="hidden" name="billing_addr_zipsubmit" id="billing_addr_zipsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_zip', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_zip_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="donor_email_address_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="donor_email_addressname">Email Address:</label>
<input type="text" name="donor_email_addressname" id="donor_email_addressname" value="" maxlength="255" class="div_17309960962980_loadingmsg" title=" " use_class="div_17309960962980_loadingmsg" tip_pos="right">
<input type="hidden" name="donor_email_addresssubmit" id="donor_email_addresssubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_email_address', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_email_address_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div class="form-row form-checkbox" id="donor_email_opt_in_Row">
<div class="form-content">
<span class="check-box-form-label-text"></span>
<input type="checkbox" name="donor_email_opt_inname" id="donor_email_opt_inname" checked="checked" onclick="fire_obs_comp_event('donor_email_opt_in', this);">
<label for="donor_email_opt_inname"> By taking action, you will be signed up for our monthly eNewsletter and communications about our work. You can unsubscribe at any time. </label>
<script type="text/javascript">
var comp = new ObservableComponent('donor_email_opt_in', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_email_opt_in_Row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('donor_email_opt_inname')) {
document.getElementById('donor_email_opt_inname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('donor_email_opt_inname')) return document.getElementById('donor_email_opt_inname').checked;
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
<input type="hidden" name="donor_email_opt_insubmit" id="donor_email_opt_insubmit" value="true">
</div>
</div>
<div class="custom-field-container form-row ">
<div class="form-content">
<div class="form-input-label-block">
<label for="mobile_phone_number_input">Mobile Phone Number</label>
</div>
<input type="text" name="mobile_phone_number_input" id="mobile_phone_number_input" value="" maxlength="255">
<input type="hidden" name="mobile_phone_numbersubmit" id="mobile_phone_numbersubmit" value="true">
</div>
</div>
<h2 class="section-header-container"> Payment Information </h2>
<div class="payment-type-element-container clearfix">
<div class="payment-type-selection-container payment-field-container">
<h3>Select a Payment Method</h3>
<div id="paymenttypecont">
<div class="paymenttypesdiv selected">Credit Card</div>
<div class="paymenttypesdiv">Bank Account</div>
<div class="paymenttypesdiv paypal"><span style="display: none;">Paypal</span></div>
</div>
<div id="responsive_payment_typepay_typeradio_row" class="form-row">
<div class="form-content">
<div class="payment-type-selections" id="responsive_payment_typepay_typeradio_payment_types">
<span class="internal-payment"><span class="payment-type-option selected"><input type="radio" name="responsive_payment_typepay_typeradio" id="responsive_payment_typepay_typeradiocredit" value="credit" checked="checked"
onclick="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" onkeypress="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);"><span class="don_radio_a"
id="responsive_payment_typepay_typeradiocredit_a"><img class="don_checkbox_img" id="responsive_payment_typepay_typeradiocredit_img" data-radgroup="responsive_payment_typepay_typeradio"
src="../bb/images/es2016_radio_button_click.png"></span><label for="responsive_payment_typepay_typeradiocredit"><a href="javascript:void(0);" class="payment-type-label">Credit Card</a></label>
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_typepay_typeradio', 'name');
</script><noscript> </noscript>
</span><span class="payment-type-option"><input type="radio" name="responsive_payment_typepay_typeradio" id="responsive_payment_typepay_typeradioach" value="ach"
onclick="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" onkeypress="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);"><span class="don_radio_a"
id="responsive_payment_typepay_typeradioach_a"><img class="don_checkbox_img" id="responsive_payment_typepay_typeradioach_img" data-radgroup="responsive_payment_typepay_typeradio"
src="../bb/images/es2016_radio_button_unclick.png"></span><label for="responsive_payment_typepay_typeradioach"><a href="javascript:void(0);" class="payment-type-label">Bank Account</a></label>
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_typepay_typeradio', 'name');
</script><noscript> </noscript>
</span></span>
<span class="external-payment"><span class="payment-type-option"><input type="radio" name="responsive_payment_typepay_typeradio" id="responsive_payment_typepay_typeradiopaypal" value="paypal"
onclick="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" onkeypress="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);"><span class="don_radio_a"
id="responsive_payment_typepay_typeradiopaypal_a"><img class="don_checkbox_img" id="responsive_payment_typepay_typeradiopaypal_img" data-radgroup="responsive_payment_typepay_typeradio"
src="../bb/images/es2016_radio_button_unclick.png"></span><label
for="responsive_payment_typepay_typeradiopaypal"><a href="javascript:void(0);" class="payment-type-label"><img src="../images/payment/paypal-logo.png" alt="Pay with Paypal"></a></label>
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_typepay_typeradio', 'name');
</script><noscript> </noscript>
</span></span>
</div>
<input type="hidden" name="responsive_payment_typepay_typeradiosubmit" id="responsive_payment_typepay_typeradiosubmit" value="true">
<script type="text/javascript">
Y.use("jquery-ui", function(Y) {
jQuery(function() {
// subscribe observable for payment type options
jQuery('.payment-type-option').each(function() {
var syncAction = function(obj) {
if (obj.hasClass('selected')) {
var radioGroupName = obj.find('input').attr('name');
obj.find('input').prop('checked', true);
fire_obs_comp_event(radioGroupName, obj.find('input').get());
}
return arguments.callee;
}(jQuery(this));
jQuery(this).click(function() {
jQuery('.payment-type-option').removeClass('selected');
jQuery(this).addClass('selected');
syncAction(jQuery(this));
var selectedValue = jQuery(this).find('input').val();
if (selectedValue == 'paypal' || selectedValue == 'amazon') {
// open up a boxinator dialog
jQuery(document).trigger('redirect-external');
jQuery('#btn_next').click();
}
});
});
});
});
var comp = new ObservableRadioComponent('responsive_payment_typepay_typeradio', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typepay_typeradio_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
</div>
<div id="payment_cc_container" class="payment-field-container">
<h3>Credit Card Information</h3>
<div id="responsive_payment_typecc_type_row" class="form-row form-radio-array">
<div class="form-content">
<fieldset>
<legend>Credit Card Type:</legend>
<ul class="radio-array-list">
<li class="tender-row ">
<img src="../images/diners_sm.gif" alt="Diners Club" name="responsive_payment_typecc_type_Diners_Club" id="responsive_payment_typecc_type_Diners_Club">
</li>
<li class="tender-row ">
<img src="../images/discovercard_sm.gif" alt="Discover" name="responsive_payment_typecc_type_Discover" id="responsive_payment_typecc_type_Discover">
</li>
<li class="tender-row ">
<img src="../images/amex_small.gif" alt="American Express" name="responsive_payment_typecc_type_American_Express" id="responsive_payment_typecc_type_American_Express">
</li>
<li class="tender-row ">
<img src="../images/mastercd_small.gif" alt="MasterCard" name="responsive_payment_typecc_type_MasterCard" id="responsive_payment_typecc_type_MasterCard">
</li>
<li class="tender-row ">
<img src="../images/visa_small.gif" alt="Visa" name="responsive_payment_typecc_type_Visa" id="responsive_payment_typecc_type_Visa">
</li>
</ul>
</fieldset>
<input type="hidden" name="responsive_payment_typecc_typesubmit" id="responsive_payment_typecc_typesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_typecc_type', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_type_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typecc_number_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typecc_numbername">Credit Card Number:</label>
<input type="text" name="responsive_payment_typecc_numbername" id="responsive_payment_typecc_numbername" value="" maxlength="22" autocomplete="off">
<div class="creditcardimg_div"></div>
<input type="hidden" name="responsive_payment_typecc_numbersubmit" id="responsive_payment_typecc_numbersubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typecc_number', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_number_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('null', new ComponentDisplayer('responsive_payment_typecc_number'));
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typecc_exp_date_row" class="form-row form-date">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typecc_exp_date_MONTH">
<span class="label-text">Expiration Date:</span><span class="aural-only">Select month of credit card</span>
</label>
<label for="responsive_payment_typecc_exp_date_YEAR"><span class="aural-only">Select Expiration Year</span></label>
<div class="date-input-container">
<fieldset class="cardExpGroup">
<select name="responsive_payment_typecc_exp_date_MONTH" id="responsive_payment_typecc_exp_date_MONTH" onchange="fire_obs_comp_event('responsive_payment_typecc_exp_date_MONTH', this)">
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8">08</option>
<option value="9">09</option>
<option value="10">10</option>
<option value="11" selected="selected">11</option>
<option value="12">12</option>
</select>
<select name="responsive_payment_typecc_exp_date_YEAR" id="responsive_payment_typecc_exp_date_YEAR" onchange="fire_obs_comp_event('responsive_payment_typecc_exp_date_YEAR', this)">
<option value="2024" selected="selected">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>
</select>
</fieldset>
<input type="hidden" name="responsive_payment_typecc_exp_date_DAY" id="responsive_payment_typecc_exp_date_DAY" value="1">
<script type="text/javascript">
<!--
var comp1 = new ObservableComponent('responsive_payment_typecc_exp_date_MONTH', '');
comp1.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_exp_date_Row', _display);
this.disable_submit_flag(_hidden);
}
var comp2 = new ObservableComponent('responsive_payment_typecc_exp_date_YEAR', '');
comp2.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_exp_date_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script><noscript> </noscript>
</div>
<input type="hidden" name="responsive_payment_typecc_exp_datesubmit" id="responsive_payment_typecc_exp_datesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typecc_exp_date', 'input');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_exp_date_row', _display);
disable_submit_flag('responsive_payment_typecc_exp_datesubmit', _hidden);
}
comp.disable = function(_disabled) {
disable_element('responsive_payment_typecc_exp_date_MONTH', _disabled);
disable_element('responsive_payment_typecc_exp_date_DAY', _disabled);
disable_element('responsive_payment_typecc_exp_date_YEAR', _disabled);
disable_element('responsive_payment_typecc_exp_date_HOUR12', _disabled);
disable_element('responsive_payment_typecc_exp_date_HOUR24', _disabled); //For UK, 24 hour clock used
disable_element('responsive_payment_typecc_exp_date_MINUTE', _disabled);
disable_element('responsive_payment_typecc_exp_date_AMPM', _disabled);
}
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typecc_cvv_row" class="form-row form-text cvv-input">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typecc_cvvname">
<span class="FormLabelText">CVV Number:</span>
</label>
<a href="http://help.convio.net/site/PageServer?s_site=es&pagename=user_donation_cvv" class="HelpLink" title="What is this? Opens new window.">What is this?</a>
<input type="text" name="responsive_payment_typecc_cvvname" id="responsive_payment_typecc_cvvname" value="" maxlength="4" autocomplete="cc-csc"><a title="Whats this?" id="cvv-help">?</a>
<input type="hidden" name="responsive_payment_typecc_cvvsubmit" id="responsive_payment_typecc_cvvsubmit" value="true">
<script type="text/javascript">
//chrome is mapping cvv as card name
if (/CriOS/.test(navigator.userAgent) || (/Chrome/.test(navigator.userAgent) && /Google Inc/.test(navigator.vendor))) {
document.getElementById('responsive_payment_typecc_cvvname').autocomplete = 'cc-csc';
}
var comp = new ObservableComponent('responsive_payment_typecc_cvv', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_cvv_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
</div>
<div id="payment_bank_container" class="payment-field-container" style="display: none;">
<h3>Checking Account Information</h3>
<div id="responsive_payment_typerouting_number_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typerouting_numbername">Bank Routing Number:</label>
<a href="http://help.convio.net/site/PageServer?s_site=es&pagename=User_Donation_ACH" class="HelpLink" title="What is this? Opens new window.">What is this?</a>
<input type="text" name="responsive_payment_typerouting_numbername" id="responsive_payment_typerouting_numbername" value="" size="20" maxlength="20" onchange="fire_obs_comp_event('responsive_payment_typerouting_number', this);"
autocomplete="off">
<input type="hidden" name="responsive_payment_typerouting_numbersubmit" id="responsive_payment_typerouting_numbersubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typerouting_number', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typerouting_number_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typebank_account_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typebank_accountname">Bank Account Number:</label>
<input type="text" name="responsive_payment_typebank_accountname" id="responsive_payment_typebank_accountname" value="" maxlength="20" autocomplete="off">
<input type="hidden" name="responsive_payment_typebank_accountsubmit" id="responsive_payment_typebank_accountsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typebank_account', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typebank_account_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('null', new ComponentDisplayer('responsive_payment_typebank_account'));
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typeverify_bank_account_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typeverify_bank_accountname">Verify Bank Account Number:</label>
<input type="text" name="responsive_payment_typeverify_bank_accountname" id="responsive_payment_typeverify_bank_accountname" value="" maxlength="20" autocomplete="off">
<input type="hidden" name="responsive_payment_typeverify_bank_accountsubmit" id="responsive_payment_typeverify_bank_accountsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typeverify_bank_account', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typeverify_bank_account_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('null', new ComponentDisplayer('responsive_payment_typeverify_bank_account'));
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_type.account_type_row" class="form-row form-radio-array">
<div class="form-content">
<fieldset>
<legend><span class="field-required"></span> Account Type:</legend>
<ul class="radio-array-list">
<li>
<input type="radio" name="responsive_payment_type.account_type" id="responsive_payment_type.account_type_responsive_payment_typeaccount_type_checking" value="CHECKING"
onclick="fire_obs_comp_event('responsive_payment_type.account_type', this);"><span class="don_radio_a" id="responsive_payment_type.account_type_responsive_payment_typeaccount_type_checking_a"><img class="don_checkbox_img"
id="responsive_payment_type.account_type_responsive_payment_typeaccount_type_checking_img" data-radgroup="responsive_payment_type.account_type" src="../bb/images/es2016_radio_button_unclick.png"></span>
<span class="radio-label">
<label for="responsive_payment_type.account_type_responsive_payment_typeaccount_type_checking">Checking</label>
</span>
</li>
<li>
<input type="radio" name="responsive_payment_type.account_type" id="responsive_payment_type.account_type_responsive_payment_typeaccount_type_savings" value="SAVINGS"
onclick="fire_obs_comp_event('responsive_payment_type.account_type', this);"><span class="don_radio_a" id="responsive_payment_type.account_type_responsive_payment_typeaccount_type_savings_a"><img class="don_checkbox_img"
id="responsive_payment_type.account_type_responsive_payment_typeaccount_type_savings_img" data-radgroup="responsive_payment_type.account_type" src="../bb/images/es2016_radio_button_unclick.png"></span>
<span class="radio-label">
<label for="responsive_payment_type.account_type_responsive_payment_typeaccount_type_savings">Savings</label>
</span>
</li>
</ul>
</fieldset>
<input type="hidden" name="responsive_payment_type.account_typesubmit" id="responsive_payment_type.account_typesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_type.account_type', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_type.account_type_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typeach_confirm_row" class="form-row form-checkbox">
<div class="form-content">
<input type="checkbox" name="responsive_payment_typeach_confirmname" id="responsive_payment_typeach_confirmname" onclick="fire_obs_comp_event('responsive_payment_typeach_confirm', this);">
<label for="responsive_payment_typeach_confirmname"><span class="field-required"></span>By checking this option, I agree to use my bank account as a payment method and authorize this organization to debit my bank account to fulfill my
donation commitment.</label>
<input type="hidden" name="responsive_payment_typeach_confirmsubmit" id="responsive_payment_typeach_confirmsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typeach_confirm', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typeach_confirm_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('responsive_payment_typeach_confirmname')) {
document.getElementById('responsive_payment_typeach_confirmname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('responsive_payment_typeach_confirmname')) {
return document.getElementById('responsive_payment_typeach_confirmname').checked;
}
}
comp.clear = function() {
this.set(false);
}
observe_component('null', new ComponentEnabler('responsive_payment_typeach_confirm'));
</script><noscript> </noscript>
</div>
</div>
</div>
<div id="payment_check_container" class="payment-field-container" style="display: none;">
<h3>Check Information</h3>
</div>
<input type="hidden" name="cc_available" id="cc_available" value="null">
<input type="hidden" name="debit_available" id="debit_available" value="null">
<input type="hidden" name="paypal_available" id="paypal_available" value="null">
<input type="hidden" name="wallets_available" id="wallets_available" value="null">
<input type="hidden" name="secure_url" id="secure_url" value="https://secure.easterseals.com/site/">
<input type="hidden" name="is_admin_app" id="is_admin_app" value="F">
<input type="hidden" name="environment_id" id="environment_id" value="">
<input type="hidden" name="merchant_account_configuration_id" id="merchant_account_configuration_id" value="">
<input type="hidden" name="pco_javascript_location" id="pco_javascript_location" value="">
<input type="hidden" name="primary_color" id="primary_color" value="null">
<input type="hidden" name="pco_language_locale" id="pco_language_locale" value="en_US">
<input type="hidden" name="pco_environment_zone" id="pco_environment_zone" value="p-usa01">
<input type="hidden" name="responsive_payment_typesubmit" id="responsive_payment_typesubmit" value="true">
<script type="text/javascript">
function PaymentObserver() {
this.observe = function(_event) {
var sVal = _event.component.get();
switch (sVal) {
case 'check':
hide_element('payment_cc_container');
hide_element('payment_bank_container');
show_element('payment_check_container');
break;
case 'credit':
hide_element('payment_bank_container');
hide_element('payment_check_container');
show_element('payment_cc_container');
break;
case 'ach':
hide_element('payment_cc_container');
hide_element('payment_check_container');
show_element('payment_bank_container');
break;
case 'paypal':
case 'amazon':
case 'mobilepay':
default:
// hide all
hide_element('payment_bank_container');
hide_element('payment_cc_container');
hide_element('payment_check_container');
break;
}
}
}
// Set the observer to show/hide the relevant fields
observe_component('responsive_payment_typepay_typeradio', new PaymentObserver());
</script><noscript> </noscript>
</div>
<input type="hidden" name="combination_seenhidden" id="combination_seenhidden" value="">
<div class="form-row">
<div class="html-caption-container">
<fieldset id="transaction-fee-area"><input id="transaction-fee-checkbox" type="checkbox"> <label id="transaction-fee-label" class="custom-element-checkbox-label" for="transaction-fee-checkbox">I would like to cover the credit card fee <span
id="fee-amount">($0.00)</span> so 100% of my gift goes to <span id="fee-site-name">Easterseals</span>.</label></fieldset>
</div>
</div>
<div class="button-container clearfix">
<div class="button-sub-container">
<button class="step-button action-button finish-step" type="submit" id="pstep_finish" name="pstep_finish" value="Donate">Donate</button>
<div id="gift-plus-fee">Total Gift:<br><strong>$0.00</strong><span id="each-month-identifier"></span></div>
</div>
</div>
<input type="hidden" name="idb" id="idb" value="1475501833">
<input type="hidden" name="df_id" id="df_id" value="21645">
<input type="hidden" name="mfc_pref" id="mfc_pref" value="T">
<div class="form-row">
<div class="html-caption-container">
<table id="ssl-secured-seal" width="135" border="0" cellpadding="2" cellspacing="0" title="Click to Verify - This site chose GeoTrust SSL for secure e-commerce and confidential communications." class="matching-gift-fund">
<tbody>
<tr>
<td width="135" align="center" valign="top">
<!-- DigiCert Seal HTML -->
<!-- Place HTML on your site where the seal should appear -->
<div id="DigiCertClickID_jRYEKqSz">
<div id="DigiCertClickID_jRYEKqSzSeal"
style="text-decoration: none; text-align: center; display: block; vertical-align: baseline; font-size: 100%; font-style: normal; text-indent: 0px; line-height: 1; width: auto; margin: 0px auto; padding: 0px; border: 0px; background: transparent; position: relative; inset: 0px; clear: both; float: none; cursor: default;">
<img src="//seal.digicert.com/seals/cascade/?tag=jRYEKqSz&referer=secure.easterseals.com&format=png&an=min" alt="DigiCert Secured Site Seal" tabindex="0" role="link"
style="text-decoration: none; text-align: center; display: block; vertical-align: baseline; font-size: 100%; font-style: normal; text-indent: 0px; line-height: 1; width: auto; margin: 0px auto; padding: 0px; border: 0px; background: transparent; position: relative; inset: 0px; clear: both; float: none; cursor: pointer;">
</div>
</div>
<!-- DigiCert Seal Code -->
<!-- Place with DigiCert Seal HTML or with other scripts -->
<script type="text/javascript">
var __dcid = __dcid || [];
__dcid.push({
"cid": "DigiCertClickID_jRYEKqSz",
"tag": "jRYEKqSz"
});
(function() {
var cid = document.createElement("script");
cid.async = true;
cid.src = "//seal.digicert.com/seals/cascade/seal.min.js";
var s = document.getElementsByTagName("script");
var ls = s[(s.length - 1)];
ls.parentNode.insertBefore(cid, ls.nextSibling);
}());
</script>
<script async="" src="//seal.digicert.com/seals/cascade/seal.min.js"></script>
</td>
</tr>
</tbody>
</table>
</div>
</div>
<div class="matching-gift-fund">By making a donation, you give us permission to use your gift, when applicable, combined with those of other donors, as part of our matching gift fund to inspire more donors like you to support our mission.
Whether or not your gift is matched, it will still be tax deductible to the full extent allowable by IRS regulations in the same year it was made. If you donate after December 31, your donation will be matched in the following year.</div>
</div>
<input type="hidden" name="21645.donation" id="21645.donation" value="form1">
</div>
<div id="don_mailbottombox" class="donation-form-container responsive">
<div id="postaladdress_wrap"> </div>
</div>
<script type="text/javascript">
var submitted = false;
function checkDoubleClick() {
var elCheck = '';
if (elCheck == 'el') {
alert('Form submission is not enabled when previewing an individual data element.');
return false;
} else if (submitted) {
alert('You have already submitted this payment. Please wait....');
return false;
} else {
submitted = true;
return true;
}
}
</script><noscript> </noscript>
</form>Text Content
Login | Register | En Español | Need Help? All Abilities. Limitless Possibilities. Donate to Easterseals today! We’re incredibly proud of the support we’re able to offer our nation’s veterans, especially when they have nowhere else to turn. But whether it’s helping veterans access health care, employment, child care, or other specialized services we count on supporters like YOU to power our vital programs and services for veterans and military families. Make your gift today to help support our programs and services for veterans, military families, and all the people who benefit from Easterseals. Field Is Required SELECT AN AMOUNT $15 $25 $50 $100 $15 $25 $35 $50 Enter amount Minimum donation amount is $5 Gift type: One-time gift Monthly gift Select a Gift Duration: Forever(Monthly) 12 months Required Giving a monthly donation is the best way to make an impact. You may cancel or change this monthly donation at any time. Additional Amount: I would like to make this gift in honor or memory of someone special Honor Gift Type: In Memory of In Honor of Required Honoree Title: Mr. Ms. Mrs. Miss Dr. Required Honoree Name: NOTIFICATION RECIPIENT INFORMATION Notification Recipient Title: Mr. Ms. Mrs. Miss Dr. Required Notification Recipient Name: Notification Recipient Street 1: Notification Recipient Street 2: Notification Recipient City: Notification Recipient State/Province: AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida GA - Georgia HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming AS - American Samoa FM - Federated States of Micronesia GU - Guam MH - Marshall Islands MP - Northern Mariana Islands PR - Puerto Rico PW - Palau VI - Virgin Islands AA - Armed Forces Americas AE - Armed Forces AP - Armed Forces Pacific AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NL - Newfoundland and Labrador NS - Nova Scotia NT - Northwest Territories NU - Nunavut ON - Ontario PE - Prince Edward Island QC - Quebec SK - Saskatchewan YT - Yukon None Required Notification Recipient ZIP Code: MESSAGE TO NOTIFICATION RECIPIENT Message Body: Message Closing: Message Signature: Yes, include the gift amount in the message. BILLING INFORMATION First Name: Last Name: Street 1: Street 2: City: State/Province: AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida GA - Georgia HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming AS - American Samoa FM - Federated States of Micronesia GU - Guam MH - Marshall Islands MP - Northern Mariana Islands PR - Puerto Rico PW - Palau VI - Virgin Islands AA - Armed Forces Americas AE - Armed Forces AP - Armed Forces Pacific AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NL - Newfoundland and Labrador NS - Nova Scotia NT - Northwest Territories NU - Nunavut ON - Ontario PE - Prince Edward Island QC - Quebec SK - Saskatchewan YT - Yukon None Required ZIP/Postal Code: Email Address: By taking action, you will be signed up for our monthly eNewsletter and communications about our work. You can unsubscribe at any time. Mobile Phone Number PAYMENT INFORMATION SELECT A PAYMENT METHOD Credit Card Bank Account Paypal Credit Card Bank Account CREDIT CARD INFORMATION Credit Card Type: * * * * * Credit Card Number: Expiration Date:Select month of credit card Select Expiration Year 01 02 03 04 05 06 07 08 09 10 11 12 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 CVV Number: What is this? ? CHECKING ACCOUNT INFORMATION Bank Routing Number: What is this? Bank Account Number: Verify Bank Account Number: Account Type: * Checking * Savings By checking this option, I agree to use my bank account as a payment method and authorize this organization to debit my bank account to fulfill my donation commitment. CHECK INFORMATION I would like to cover the credit card fee ($0.00) so 100% of my gift goes to Easterseals. Donate Total Gift: $0.00 By making a donation, you give us permission to use your gift, when applicable, combined with those of other donors, as part of our matching gift fund to inspire more donors like you to support our mission. Whether or not your gift is matched, it will still be tax deductible to the full extent allowable by IRS regulations in the same year it was made. If you donate after December 31, your donation will be matched in the following year. × Credit Card Verification Code The Verification Code is imprinted on credit cards to help merchants verify transactions when the actual card is not present, such as Internet purchases or donations. The merchant uses this number as part of the authorization process with the card issuer. Visa, Master Card, and Discover: The verification code for Visa, Master Card, and Discover is a 3-digit number printed on the back of your card. It appears after the account number or last 4-digits of your account number, in the signature panel. American Express: The American Express verification code is a 4-digit number printed on the front of your card. It appears above and to the right of the embossed account number. OTHER WAYS TO GIVE Easterseals is changing the way the world defines and views disability by making profound, positive differences in people's lives every day. Planned Giving Go Workplace Giving Go Donate Cryptocurrency Go Easterseals 141 W Jackson Blvd, Suite 1400A, Chicago, IL 60604 | 800-221-6827 (toll-free) Easterseals and its affiliate organizations are 501(c)(3) nonprofit organizations. Easterseals 141 W Jackson Blvd, Suite 1400A Chicago, IL 60604 | 800-221-6827 (toll-free) Easterseals and its affiliate organizations are 501(c)(3) nonprofit organizations. ©2024 Easterseals | Privacy Policy/Your California Privacy Rights | Accessibility Guidelines | Site Map | Contact Us ©2024 Easterseals | Privacy Policy/Your California Privacy Rights Accessibility Guidelines | Site Map | Contact Us ©2024 Easterseals Privacy Policy/Your California Privacy Rights Accessibility Guidelines Site Map | Contact Us