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2606:4700:3035::ac43:a1d0  Public Scan

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Submitted URL: https://la4rccs.com/
Effective URL: https://www.rccscancer.org/donate-la/
Submission: On March 09 via api from US — Scanned from US

Form analysis 1 forms found in the DOM

Name: orderInfo — POST https://www.rccscancer.org/donate-la/?eventname=donate-la

<form name="orderInfo" id="orderInfo" method="post" action="https://www.rccscancer.org/donate-la/?eventname=donate-la" onsubmit="return validatorPayment(document.orderInfo);">
  <input name="itemQtyX" type="hidden" valu="0">
  <input name="itemTotalX" type="hidden">
  <input name="itempriceX" type="hidden" value="0">
  <input id="step2" name="step2" type="checkbox" style="display:none;">
  <input name="itemfreex" type="hidden">
  <input name="itemQtyX" type="hidden" valu="0">
  <input name="itemTotalX" type="hidden">
  <input name="itempriceX" type="hidden" value="0">
  <input id="step3" type="checkbox" style="display:none;">
  <input name="itemfreex" type="hidden">
  <input name="itemQtyX" type="hidden" valu="0">
  <input name="itemTotalX" type="hidden">
  <input name="itempriceX" type="hidden" value="0">
  <input id="step4" type="checkbox" style="display:none;">
  <input name="itemfreex" type="hidden">
  <div id="donatepart" class="form-group">
    <div class="donationoptions">
      <input type="radio" class="dn-checkbox" name="misc2" id="donation18000" value="Full Year Family Policy Patron" onclick="updateAmount('18000');"><label for="donation18000">
        <div class="amount">$18,000</div>
        <div class="desc">Full Year Family Policy Patron </div>
      </label>
      <input type="radio" class="dn-checkbox" name="misc2" id="donation9000" value="Half Year Family Policy Patron" onclick="updateAmount('9000');"><label for="donation9000">
        <div class="amount">$9,000</div>
        <div class="desc">Half Year Family Policy Patron</div>
      </label>
      <input type="radio" class="dn-checkbox" name="misc2" id="donation6000" value="Full Year Personal Policy Patron" onclick="updateAmount('6000');"><label for="donation6000">
        <div class="amount">$6,000</div>
        <div class="desc">Full Year Personal Policy Patron</div>
      </label>
      <input type="radio" class="dn-checkbox" name="misc2" id="donation3600" value="Quarter Year Family Policy Patron" onclick="updateAmount('3600');"><label for="donation3600">
        <div class="amount">$3,600</div>
        <div class="desc">Quarter Year Family Policy Patron</div>
      </label>
      <input type="radio" class="dn-checkbox" name="misc2" id="donation1500" value="One Month Family Policy Patron" onclick="updateAmount('1500');"><label for="donation1500">
        <div class="amount">$1,500</div>
        <div class="desc">One Month Family Policy Patron</div>
      </label>
      <input type="radio" class="dn-checkbox" name="misc2" id="donation1200" value="Two Month Single Policy Patron" onclick="updateAmount('1200');"><label for="donation1200">
        <div class="amount">$1,200</div>
        <div class="desc">Two Month Single Policy Patron</div>
      </label>
      <input type="radio" class="dn-checkbox" name="misc2" id="donation600" value="One Month Single Policy Patron" onclick="updateAmount('600');"><label for="donation600">
        <div class="amount">$600</div>
        <div class="desc">One Month Single Policy Patron</div>
      </label>
      <input type="radio" class="dn-checkbox" name="misc2" id="donation360" value="One Week Family Policy Patron" onclick="updateAmount('360');"><label for="donation360">
        <div class="amount">$360</div>
        <div class="desc">One Week Family Policy Patron</div>
      </label>
      <dt class="dn-head view">View Sponsorship Opportunties <i class="fa fa-plus"></i></dt>
      <dd style="display: none;">
        <input type="radio" class="dn-checkbox" name="misc2" id="donationLa25000" value="Event Sponsor" onclick="updateAmount('25000');"><label for="donationLa25000">
          <div class="amount">$25,000</div>
          <div class="desc">Event Sponsor</div>
        </label>
        <input type="radio" class="dn-checkbox" name="misc2" id="donationLa18000" value="Entertainment Sponsor" onclick="updateAmount('18000');"><label for="donationLa18000">
          <div class="amount">$18,000</div>
          <div class="desc">Entertainment Sponsor</div>
        </label>
        <input type="radio" class="dn-checkbox" name="misc2" id="donationLa10000" value="Food Sponsor" onclick="updateAmount('10000');"><label for="donationLa10000">
          <div class="amount">$10,000</div>
          <div class="desc">Food Sponsor</div>
        </label>
        <input type="radio" class="dn-checkbox" name="misc2" id="donationLa7500" value="Bar Sponsor" onclick="updateAmount('7500');"><label for="donationLa7500">
          <div class="amount">$7,500</div>
          <div class="desc">Bar Sponsor</div>
        </label>
        <input type="radio" class="dn-checkbox" name="misc2" id="donationLa5000" value="Diamond  Sponsor" onclick="updateAmount('5000');"><label for="donationLa5000">
          <div class="amount">$5,000</div>
          <div class="desc">Diamond Sponsor</div>
        </label>
        <input type="radio" class="dn-checkbox" name="misc2" id="donationLa3600" value="Platinum  Sponsor" onclick="updateAmount('3600');"><label for="donationLa3600">
          <div class="amount">$3,600</div>
          <div class="desc">Platinum Sponsor</div>
        </label>
        <input type="radio" class="dn-checkbox" name="misc2" id="donationLa2500" value="Gold Sponsor" onclick="updateAmount('2500');"><label for="donationLa2500">
          <div class="amount">$2,500</div>
          <div class="desc">Gold Sponsor</div>
        </label>
        <input type="radio" class="dn-checkbox" name="misc2" id="donationLa1800" value="Silver Sponsor" onclick="updateAmount('1800');"><label for="donationLa1800">
          <div class="amount">$1,800</div>
          <div class="desc">Silver Sponsor</div>
        </label>
      </dd>
    </div>
    <div class="dn-field float third currency">
      <select class="dn-textfield" id="currency" name="currency" onchange="updateDonation();" required="">
        <option value="USD" selected="selected">USD</option>
        <option value="CAD">CAD</option>
      </select>
    </div>
    <div class="clear"></div>
    <div class="enter">Enter donation amount</div>
    <div class="amount"><span>$</span><input name="OrderTotal" class="dn-textfield group1" type="number" min="5" step=".01" id="OrderTotal" value="" onchange="CheckMinimum();updateDonation();" autocomplete="OFF" required=""></div>
    <div class="options">
      <label class="script" for="chargeOneTime">one time <input class="dn-checkbox" name="recurringType" id="chargeOneTime" type="radio" onclick="changeDisplay('InstallDiv','none');changeDisplay('RecurDiv','none');updateDonation();" value="once"
          checked="">
        <span class="newmark"></span>
      </label>
      <br>
      <label class="script" for="chargeRecurring">recurring <input class="dn-checkbox" type="radio" name="recurringType" value="recurring" id="chargeRecurring"
          onclick="changeDisplay('InstallDiv','none');changeDisplay('RecurDiv','block');updateDonation();">
        <span class="newmark"></span>
      </label>
      <div id="InstallDiv" class="installment" style="display:none;"><input name="recurringLength" type="number" id="recurringLength" class="dn-textfield" min="2" step="1" max="12" onchange="updateDonation();"> Months</div>
      <div id="RecurDiv" style="display:none;">
        <div class="dn-field float half">
          <select name="recurringOption" id="recurringOption" class="dn-textfield group1" onchange="updateDonation();">
            <option value=""> -- Select One --</option>
            <option value="weekly">Weekly</option>
            <option value="biweekly">Biweekly</option>
            <option value="monthly">Monthly</option>
            <option value="bimonthly">Bimonthly</option>
          </select>
        </div>
        <div class="dn-clear"></div>
      </div>
      <input type="hidden" name="recurringAmount" class="dn-textfieldsml" id="recurringAmount" autocomplete="OFF">
      <input type="hidden" name="recurring" value="" id="recurring">
    </div>
    <dt class="honor caps">Give in Honor/Memory of Someone <i class="fa fa-plus"></i></dt>
    <dd id="DedicationDiv" style="display:none;">
      <div class="dn-spacer"></div>
      <div class="dn-head">Dedication Information</div>
      <div class="dn-field">
        <input type="radio" name="donationType" value="General Donation" id="General">
        <label for="General">General Donation</label> &nbsp; <input type="radio" name="donationType" value="In Memory of" id="Memory">
        <label for="Memory">In Memory Of</label><br>
        <input type="radio" name="donationType" value="In Honor of" id="Honor">
        <label for="Honor">In Honor Of</label> &nbsp; <input type="radio" name="donationType" value="Recovery of" id="Recovery">
        <label for="Recovery">For The Recovery Of</label>
      </div>
      <div class="dn-field">
        <input name="honorName" id="honorName" type="text" class="dn-textfield" value="" onkeyup="this.setAttribute('value', this.value);">
        <span class="dn-title">Name</span>
      </div>
      <span class="dn-smalltext">To have us notify them/their family a gift has been made in their name, please enter an address or email address, and your message</span>
      <div class="dn-spacer"></div>
      <div class="dn-field">
        <input name="honorEmail" id="honorEmail" type="text" class="dn-textfield" value="" onkeyup="this.setAttribute('value', this.value);">
        <span class="dn-title">Email Address</span>
      </div>
      <div class="dn-field" style="display:none;">
        <textarea name="honorAddress" id="honorAddress" class="dn-textfield" value="" onkeyup="this.setAttribute('value', this.value);"></textarea>
        <span class="dn-title">Mailing Address</span>
      </div>
      <div class="dn-field">
        <textarea name="honorComment" id="honorComment" class="dn-textfield" value="" onkeyup="this.setAttribute('value', this.value);"></textarea>
        <span class="dn-title">Message to be sent</span>
      </div>
    </dd>
    <div id="steponebutton" class="btn-group btn-group-lg" role="group" aria-label="..."><a id="continue-step1" class="continue"><div class="button">Donate</div></a></div>
  </div>
  <div id="part1" class="form-group">
    <div class="dn-head">Personal Information</div>
    <div class="dn-field">
      <input name="first_name" type="text" id="FirstName" autocapitalize="words" value="" onkeyup="this.setAttribute('value', this.value);" required="required" class="dn-textfield group2">
      <span class="dn-title">First Name <span class="dn-star">*</span></span>
    </div>
    <div class="dn-field">
      <input name="last_name" type="text" required="required" id="LastName" value="" onkeyup="this.setAttribute('value', this.value);" autocapitalize="words" class="dn-textfield group2">
      <span class="dn-title">Last Name <span class="dn-star">*</span></span>
    </div>
    <div class="display dn-field">
      <input name="displayCompany" type="checkbox" id="displayCompany" value="True" onclick="changeCheckDisplay('displayCompany','CompanyDiv');">
      <label for="displayCompany">add company name</label>
    </div>
    <div id="CompanyDiv" style="display:none;">
      <div class="dn-field">
        <input name="company" type="text" id="CompanyName" autocapitalize="words" class="dn-textfield" value="" onkeyup="this.setAttribute('value', this.value);">
        <span class="dn-title">Company Name</span>
      </div>
    </div>
    <div class="dn-field">
      <input name="address" type="text" required="required" id="BillAddress" class="dn-textfield group2" value="" onkeyup="this.setAttribute('value', this.value);">
      <span class="dn-title">Address <span class="dn-star">*</span></span>
    </div>
    <div class="dn-field float third">
      <input name="city" required="required" type="text" id="BillCity" class="dn-textfield group2" value="" onkeyup="this.setAttribute('value', this.value);">
      <span class="dn-title">City <span class="dn-star">*</span> </span>
    </div>
    <div class="dn-field float third">
      <select name="state" required="required" id="BillState" class="dn-textfield group2" value="" onkeyup="this.setAttribute('value', this.value);">
        <option value="">State *</option>
        <option value="Other">Outside US &amp; Canada</option>
        <option value="AL">Alabama</option>
        <option value="AK">Alaska</option>
        <option value="AZ">Arizona</option>
        <option value="AR">Arkansas</option>
        <option value="CA">California</option>
        <option value="CO">Colorado</option>
        <option value="CT">Connecticut</option>
        <option value="DE">Delaware</option>
        <option value="DC">District of Columbia</option>
        <option value="FL">Florida</option>
        <option value="GA">Georgia</option>
        <option value="HI">Hawaii</option>
        <option value="ID">Idaho</option>
        <option value="IL">Illinois</option>
        <option value="IN">Indiana</option>
        <option value="IA">Iowa</option>
        <option value="KS">Kansas</option>
        <option value="KY">Kentucky</option>
        <option value="LA">Louisiana</option>
        <option value="ME">Maine</option>
        <option value="MD">Maryland</option>
        <option value="MA">Massachusetts</option>
        <option value="MI">Michigan</option>
        <option value="MN">Minnesota</option>
        <option value="MS">Mississippi</option>
        <option value="MO">Missouri</option>
        <option value="MT">Montana</option>
        <option value="NE">Nebraska</option>
        <option value="NV">Nevada</option>
        <option value="NH">New Hampshire</option>
        <option value="NJ">New Jersey</option>
        <option value="NM">New Mexico</option>
        <option value="NY">New York</option>
        <option value="NC">North Carolina</option>
        <option value="ND">North Dakota</option>
        <option value="OH">Ohio</option>
        <option value="OK">Oklahoma</option>
        <option value="OR">Oregon</option>
        <option value="PA">Pennsylvania</option>
        <option value="RI">Rhode Island</option>
        <option value="SC">South Carolina</option>
        <option value="SD">South Dakota</option>
        <option value="TN">Tennessee</option>
        <option value="TX">Texas</option>
        <option value="UT">Utah</option>
        <option value="VT">Vermont</option>
        <option value="VA">Virginia</option>
        <option value="WA">Washington</option>
        <option value="WV">West Virginia</option>
        <option value="WI">Wisconsin</option>
        <option value="WY">Wyoming</option>
        <option value="AB">Alberta</option>
        <option value="BC">British Columbia</option>
        <option value="MB">Manitoba</option>
        <option value="NB">New Brunswick</option>
        <option value="NL">Newfoundland</option>
        <option value="NT">Northwest Territories</option>
        <option value="NS">Nova Scotia</option>
        <option value="ON">Ontario</option>
        <option value="PE">Prince Edward Island</option>
        <option value="QC">Quebec</option>
        <option value="SK">Saskatchewan</option>
        <option value="YT">Yukon Territory</option>
      </select>
    </div>
    <div class="dn-field float third">
      <input name="zip" required="required" type="text" id="BillZip" class="dn-textfield" value="" onkeyup="this.setAttribute('value', this.value);">
      <span class="dn-title">Zip Code <span class="dn-star">*</span> </span>
    </div>
    <div class="clear"></div>
    <div class="dn-field">
      <select name="country" required="required" id="BillCountry" class="dn-textfield" value="" onkeyup="this.setAttribute('value', this.value);">
        <!-- <option></option>-->
        <option value="US">United States</option>
        <option value="AL"> Albania </option>
        <option value="DZ"> Algeria </option>
        <option value="AS"> American Samoa </option>
        <option value="AD"> Andorra </option>
        <option value="AI"> Anguilla </option>
        <option value="AG"> Antigua </option>
        <option value="AR"> Argentina </option>
        <option value="AW"> Aruba </option>
        <option value="AU"> Australia </option>
        <option value="AT"> Austria </option>
        <option value="AP"> Azores </option>
        <option value="BS"> Bahamas </option>
        <option value="BH"> Bahrain </option>
        <option value="BD"> Bangladesh </option>
        <option value="BB"> Barbados </option>
        <option value="BC"> Barbuda </option>
        <option value="BY"> Belarus </option>
        <option value="BE"> Belgium </option>
        <option value="BZ"> Belize </option>
        <option value="BJ"> Benin </option>
        <option value="BM"> Bermuda </option>
        <option value="BO"> Bolivia </option>
        <option value="BL"> Bonaire </option>
        <option value="BW"> Botswana </option>
        <option value="BR"> Brazil </option>
        <option value="BN"> Brunei </option>
        <option value="BG"> Bulgaria </option>
        <option value="BF"> Burkina Faso </option>
        <option value="BI"> Burundi </option>
        <option value="KH"> Cambodia </option>
        <option value="CM"> Cameroon </option>
        <option value="CA"> Canada </option>
        <option value="CE"> Canary Islands </option>
        <option value="KY"> Cayman Islands </option>
        <option value="CF"> Central Africa</option>
        <option value="TD"> Chad </option>
        <option value="NN"> Channel Islands</option>
        <option value="CL"> Chile </option>
        <option value="CN"> China </option>
        <option value="CX"> Christmas Island </option>
        <option value="CC"> Cocos Islands </option>
        <option value="CO"> Colombia </option>
        <option value="CG"> Congo </option>
        <option value="CK"> Cook Islands </option>
        <option value="CR"> Costa Rica </option>
        <option value="HR"> Croatia </option>
        <option value="CB"> Curacao </option>
        <option value="CY"> Cyprus </option>
        <option value="CZ"> Czech Republic </option>
        <option value="DK"> Denmark </option>
        <option value="DJ"> Djibouti </option>
        <option value="DM"> Dominica </option>
        <option value="EC"> Ecuador </option>
        <option value="EG"> Egypt </option>
        <option value="SV"> El Salvador </option>
        <option value="EN"> England </option>
        <option value="GQ"> Equitorial Guinea</option>
        <option value="ER"> Eritrea </option>
        <option value="EE"> Estonia </option>
        <option value="ET"> Ethiopia </option>
        <option value="FO"> Faeroe Islands</option>
        <option value="FJ"> Fiji </option>
        <option value="FI"> Finland </option>
        <option value="FR"> France </option>
        <option value="GF"> French Guiana </option>
        <option value="GA"> Gabon </option>
        <option value="GM"> Gambia </option>
        <option value="DE"> Germany </option>
        <option value="GH"> Ghana </option>
        <option value="GI"> Gibraltar </option>
        <option value="GR"> Greece </option>
        <option value="GL"> Greenland </option>
        <option value="GD"> Grenada </option>
        <option value="GP"> Guadeloupe </option>
        <option value="GU"> Guam </option>
        <option value="GT"> Guatemala </option>
        <option value="GN"> Guinea </option>
        <option value="GW"> Guinea Bissau </option>
        <option value="GY"> Guyana </option>
        <option value="HT"> Haiti </option>
        <option value="HO"> Holland </option>
        <option value="HN"> Honduras </option>
        <option value="HK"> Hong Kong </option>
        <option value="HU"> Hungary </option>
        <option value="IS"> Iceland </option>
        <option value="IN"> India </option>
        <option value="ID"> Indonesia </option>
        <option value="IR"> Iran </option>
        <option value="IE"> Ireland </option>
        <option value="SB"> Islands </option>
        <option value="IL"> Israel </option>
        <option value="IT"> Italy </option>
        <option value="CI"> Ivory Coast </option>
        <option value="JM"> Jamaica </option>
        <option value="JP"> Japan </option>
        <option value="JO"> Jordan </option>
        <option value="KZ"> Kazakhstan </option>
        <option value="KE"> Kenya </option>
        <option value="KI"> Kiribati </option>
        <option value="KR"> Korea </option>
        <option value="KO"> Kosrae </option>
        <option value="KW"> Kuwait </option>
        <option value="KG"> Kyrgyzstan </option>
        <option value="LA"> Laos </option>
        <option value="LV"> Latvia </option>
        <option value="LB"> Lebanon </option>
        <option value="LS"> Lesotho </option>
        <option value="LR"> Liberia </option>
        <option value="LI"> Liechtenstein </option>
        <option value="LT"> Lithuania </option>
        <option value="LU"> Luxembourg </option>
        <option value="MO"> Macau </option>
        <option value="MK"> Macedonia </option>
        <option value="MG"> Madagascar </option>
        <option value="ME"> Madeira </option>
        <option value="MW"> Malawi </option>
        <option value="MY"> Malaysia </option>
        <option value="MV"> Maldives </option>
        <option value="ML"> Mali </option>
        <option value="MT"> Malta </option>
        <option value="MQ"> Martinique </option>
        <option value="MR"> Mauritania </option>
        <option value="MU"> Mauritius </option>
        <option value="MX"> Mexico </option>
        <option value="FM"> Micronesia </option>
        <option value="MC"> Monaco </option>
        <option value="MS"> Montserrat </option>
        <option value="MA"> Morocco </option>
        <option value="MZ"> Mozambique </option>
        <option value="MM"> Myanmar </option>
        <option value="NA"> Namibia </option>
        <option value="NP"> Nepal </option>
        <option value="NL"> Netherlands </option>
        <option value="NV"> Nevis </option>
        <option value="NC"> New Caledonia </option>
        <option value="NZ"> New Zealand </option>
        <option value="NI"> Nicaragua </option>
        <option value="NE"> Niger </option>
        <option value="NG"> Nigeria </option>
        <option value="NU"> Niue </option>
        <option value="NF"> Norfolk Island </option>
        <option value="NB"> Northern Ireland </option>
        <option value="NO"> Norway </option>
        <option value="OM"> Oman </option>
        <option value="PK"> Pakistan </option>
        <option value="PW"> Palau </option>
        <option value="PA"> Panama </option>
        <option value="PY"> Paraguay </option>
        <option value="PE"> Peru </option>
        <option value="PH"> Philippines </option>
        <option value="PL"> Poland </option>
        <option value="PO"> Ponape </option>
        <option value="PT"> Portugal </option>
        <option value="PR"> Puerto Rico </option>
        <option value="QA"> Qatar </option>
        <option value="RE"> Reunion </option>
        <option value="RO"> Romania </option>
        <option value="RT"> Rota </option>
        <option value="RU"> Russia </option>
        <option value="RW"> Rwanda </option>
        <option value="SS"> Saba </option>
        <option value="SP"> Saipan </option>
        <option value="SA"> Saudi Arabia </option>
        <option value="SF"> Scotland </option>
        <option value="SN"> Senegal </option>
        <option value="SC"> Seychelles </option>
        <option value="SL"> Sierra Leone </option>
        <option value="SG"> Singapore </option>
        <option value="SK"> Slovak Republic </option>
        <option value="SI"> Slovenia </option>
        <option value="ZA"> South Africa </option>
        <option value="ES"> Spain </option>
        <option value="LK"> Sri Lanka </option>
        <option value="NT"> St. Barthelemy </option>
        <option value="SW"> St. Christopher </option>
        <option value="SX"> St. Croix </option>
        <option value="EU"> St. Eustatius </option>
        <option value="UV"> St. John </option>
        <option value="KN"> St. Kitts </option>
        <option value="LC"> St. Lucia </option>
        <option value="MB"> St. Maarten </option>
        <option value="TB"> St. Martin </option>
        <option value="VL"> St. Thomas </option>
        <option value="VC"> St. Vincent</option>
        <option value="SD"> Sudan </option>
        <option value="SR"> Suriname </option>
        <option value="SZ"> Swaziland </option>
        <option value="SE"> Sweden </option>
        <option value="CH"> Switzerland </option>
        <option value="SY"> Syria </option>
        <option value="TA"> Tahiti </option>
        <option value="TW"> Taiwan </option>
        <option value="TJ"> Tajikistan </option>
        <option value="TZ"> Tanzania </option>
        <option value="TH"> Thailand </option>
        <option value="TI"> Tinian </option>
        <option value="TG"> Togo </option>
        <option value="TO"> Tonga </option>
        <option value="TL"> Tortola </option>
        <option value="TU"> Truk </option>
        <option value="TN"> Tunisia </option>
        <option value="TR"> Turkey </option>
        <option value="TV"> Tuvalu </option>
        <option value="UG"> Uganda </option>
        <option value="UA"> Ukraine </option>
        <option value="UI"> Union Island </option>
        <option value="AE"> United Arab Emirates </option>
        <option value="GB"> United Kingdom </option>
        <option value="UY"> Uruguay </option>
        <option value="UZ"> Uzbekistan </option>
        <option value="VU"> Vanuatu </option>
        <option value="VE"> Venezuela </option>
        <option value="VN"> Vietnam </option>
        <option value="VR"> Virgin Gorda </option>
        <option value="VI"> Virgin Islands </option>
        <option value="WK"> Wake Island </option>
        <option value="WL"> Wales </option>
        <option value="WS"> Western Samoa</option>
        <option value="YA"> Yap </option>
        <option value="YE"> Yemen </option>
        <option value="ZR"> Zaire </option>
        <option value="ZM"> Zambia </option>
        <option value="ZW"> Zimbabwe </option>
      </select>
      <!--<span class="dn-title">Country <span class="dn-star">*</span> </span>  -->
    </div>
    <div class="dn-field">
      <input name="phone" required="required" type="tel" id="Phone" class="dn-textfield group2" value="" onkeyup="this.setAttribute('value', this.value);">
      <span class="dn-title">Phone Number <span class="dn-star">*</span></span>
    </div>
    <div class="dn-field">
      <input name="Cell" type="tel" id="Cell" class="dn-textfield" value="" onkeyup="this.setAttribute('value', this.value);">
      <span class="dn-title">Cell Phone </span>
    </div>
    <div class="dn-field">
      <input name="email" type="email" required="required" id="EmailAddress" class="dn-textfield group2" value="" onkeyup="this.setAttribute('value', this.value);">
      <span class="dn-title">Email Address <span class="dn-star">*</span></span>
    </div>
    <div class="btn-group btn-group-lg btn-group-justified" role="group" aria-label="...">
      <label for="step2" id="continue-step2" class="continue">
        <div class="button right">Next</div>
      </label>
    </div>
  </div>
  <div id="part2" class="form-group">
    <div class="dn-head">Payment Details</div>
    <div class="dn-title rel">Your card will be charged <strong><span class="currencySym">$</span><span id="TotalDisplay"></span> <span id="MonthText"></span></strong></div>
    <div class="dn-spacer"></div>
    <div style="display:none; margin: 15px 0 0 0;">
      <input name="chargenow" type="radio" onclick="changeDisplay('BillLater','none');changeDisplay('CreditCardTable','block');" value="1" checked="">Charge My Card &nbsp;&nbsp; <input type="radio" name="chargenow" value="0"
        onclick="changeDisplay('BillLater','block');changeDisplay('CreditCardTable','none');">Bill Me Later <br> &nbsp;
    </div>
    <div id="BillLater" style="display:none;">
      <font color="red"><strong>YOU WILL BE BILLED LATER</strong></font><br><br><br>
    </div>
    <script>
      $j(document).ready(function() {
        $j("input[name='paymentType']").on('change', function() {
          var paymentType = $j('input[name="paymentType"]:checked').val();
          document.orderInfo['submitBtn'].style.display = 'block';
          $j('.hide-zelle').show();
          if (paymentType == 'ojc') {
            $j('#CardCode').val('000');
            $j("#CardCode, .cvv").hide();
            $j('#ExpMonth').val('');
            $j('#ExpYear').val('');
            $j('#CardType').val('ojc');
            document.getElementById('ZelleDiv').style.display = 'none';
            document.getElementById('CheckDiv').style.display = 'none';
            document.getElementById('CreditCardTable').style.display = 'block';
            // skipCC=1;
          } else if (paymentType == 'donorsfund') {
            //$j('#ExpMonth').val('12');
            //$j('#ExpYear').val('26');
            $j('#CardCode').val('');
            $j("#CardCode, .cvv").show();
            skipCC = 1;
            $j('#CardType').val('donorsfund');
            document.getElementById('ZelleDiv').style.display = 'none';
            document.getElementById('CheckDiv').style.display = 'none';
            document.getElementById('CreditCardTable').style.display = 'block';
          } else if (paymentType == 'pledger') {
            $j('#CardCode').val('');
            $j("#CardCode, .cvv").show();
            $j('#ExpMonth').val('');
            $j('#ExpYear').val('');
            $j("#CreditCardTable").addClass("inactive");
            $j('#CardType').val('pledger');
            document.getElementById('ZelleDiv').style.display = 'none';
            document.getElementById('CheckDiv').style.display = 'none';
            document.getElementById('CreditCardTable').style.display = 'block';
            skipCC = 1;
          } else if (paymentType == 'check') {
            $j('#CardCode').val('');
            $j("#CardCode, .cvv").show();
            $j('#ExpMonth').val('');
            $j('#ExpYear').val('');
            $j('#CardType').val('');
            document.getElementById('ZelleDiv').style.display = 'none';
            document.getElementById('CheckDiv').style.display = 'block';
            document.getElementById('CreditCardTable').style.display = 'none';
            document.orderInfo['submitBtn'].disabled = false;
          } else if (paymentType == 'zelle') {
            document.getElementById('ZelleDiv').style.display = 'block';
            document.getElementById('CheckDiv').style.display = 'none';
            document.getElementById('CreditCardTable').style.display = 'none';
            $j('.hide-zelle').hide();
            document.orderInfo['submitBtn'].style.display = 'none';
          } else {
            $j('#CardCode').val('');
            $j("#CardCode, .cvv").show();
            $j('#ExpMonth').val('');
            $j('#ExpYear').val('');
            $j('#CardType').val('');
            document.getElementById('ZelleDiv').style.display = 'none';
            document.getElementById('CheckDiv').style.display = 'none';
            document.getElementById('CreditCardTable').style.display = 'block';
          }
        });
      });
    </script>
    <div class="paymentoptions">
      <label class="script" for="CreditCard"><img src="https://www.rayze.it/images/icon-creditcard.png" alt="Credit Card"> Credit Card <input id="CreditCard" class="dn-checkbox" name="paymentType" type="radio" value="CC:Charge" checked=""> <span
          class="newmark"></span></label>
      <label class="script" id="checkLabel" for="check"><img src="https://www.rayze.it/images/icon-check.png" alt="Check"> Check <input id="check" class="dn-checkbox" name="paymentType" type="radio" value="check"> <span
          class="newmark"></span></label>
      <label class="script" id="ojcLabel" for="OJC"><img src="https://www.rayze.it/images/icon-ojc.png" alt="OJC"><input id="OJC" class="dn-checkbox" name="paymentType" type="radio" value="ojc"> <span class="newmark"></span></label>
      <label class="script" id="donorsfundLabel" for="donorsfund"><img src="https://www.rayze.it/images/icon-donorsfund-full.png" alt="Donors Fund"><input id="donorsfund" class="dn-checkbox" name="paymentType" type="radio" value="donorsfund"> <span
          class="newmark"></span></label>
      <label class="script" id="pledgerLabel" for="pledger"><img src="https://www.rayze.it/images/icon-pledger-full.png" alt="Pledger"><input id="pledger" class="dn-checkbox" name="paymentType" type="radio" value="pledger"> <span
          class="newmark"></span></label>
      <label class="script" for="zelle"><img src="https://www.rayze.it/images/icon-zelle.png" alt="Zelle"> <input id="zelle" class="dn-checkbox" name="paymentType" type="radio" value="zelle"> <span class="newmark"></span></label>
    </div>
    <hr>
    <div id="ZelleDiv" style="display:none;">Zelle donations can be made via your banking app to quickpay@rccscancer.org.</div>
    <div id="CheckDiv" style="display:none;">
      <div class="dn-field float half">
        <input name="chkName" type="text" id="chkName" autocapitalize="words" value="" onkeyup="this.setAttribute('value', this.value);" class="dn-textfield">
        <span class="dn-title">Account Name <span class="dn-star">*</span></span>
      </div>
      <div class="dn-field float half">
        <select type="txt" name="chkType" id="chkType" class="dn-textfield">
          <option value="">Account Type</option>
          <option value="Checking">Checking</option>
          <option value="Savings">Savings</option>
        </select>
      </div>
      <div class="dn-clear"></div>
      <div class="dn-field float half">
        <input name="chkRouting" type="number" id="chkRouting" autocapitalize="words" value="" onkeyup="this.setAttribute('value', this.value);" class="dn-textfield" autocomplete="OFF">
        <span class="dn-title">Routing Number <span class="dn-star">*</span></span>
      </div>
      <div class="dn-field float half">
        <input name="chkAccount" type="text" id="chkAccount" autocapitalize="words" value="" onkeyup="this.setAttribute('value', this.value);" class="dn-textfield">
        <span class="dn-title">Account Number <span class="dn-star">*</span></span>
      </div>
      <div class="dn-field">
        <textarea class="dn-textfield dn-textarea" name="chkAgreeWaiver"
          id="chkAgreeWaiver">I hereby authorize this company to debit my bank account through the electronic Automated Clearing House (ACH) network within one to three business days from the date of this payment. I am aware that in the event this company is unable to secure funds from my bank account for this transaction for any reason, including but not limited to, insufficient funds in my account or insufficient or inaccurate information I provided when I submitted the electronic payment, further collection action may be undertaken by this company, including application of returned check fees to the extent permitted by law. If the payment is returned by my bank, I am still responsible for making a payment to this company.</textarea>
        <input name="chkAgree" type="checkbox" id="chkAgree" value="I agree"> <label for="chkAgree">I agree to the above ACH terms and conditions</label>
      </div>
    </div>
    <div id="card-errors" role="alert" style="color:red;" tabindex="-1"></div>
    <div id="CreditCardTable" style="display:block;">
      <div style="display:none;">
        <select name="CardType" id="CardType" class="textfield">
          <option value="" disabled="" selected=""></option>
          <option value="VISA">Visa</option>
          <option value="MASTERCARD">Mastercard</option>
          <option value="AMERICANEXPRESS">American Express</option>
          <option value="DISCOVER">Discover</option>
          <option value="donorsfund">Donors Fund</option>
          <option value="ojc">OJC</option>
          <option value="pledger">Pledger</option>
        </select>
      </div>
      <div class="dn-field">
        <input name="cardnum" type="text" id="CardNumber" class="dn-textfield" value="" autocomplete="OFF" onkeyup="this.setAttribute('value', this.value);checkCardType(this.value);">
        <span class="dn-title">Card Number <span class="dn-star">*</span></span>
      </div>
      <div class="dn-field float third">
        <select name="ExpMonth" id="ExpMonth" class="dn-textfield">
          <option value="">Exp. Month * </option>
          <option value="01">01-January</option>
          <option value="02">02-February</option>
          <option value="03">03-March</option>
          <option value="04">04-April</option>
          <option value="05">05-May</option>
          <option value="06">06-June</option>
          <option value="07">07-July</option>
          <option value="08">08-August</option>
          <option value="09">09-September</option>
          <option value="10">10-October</option>
          <option value="11">11-November</option>
          <option value="12">12-December</option>
        </select>
      </div>
      <div class="dn-field float third">
        <select name="ExpYear" id="ExpYear" class="dn-textfield">
          <option value="">Exp. Year *</option>
          <option value="24">2024</option>
          <option value="25">2025</option>
          <option value="26">2026</option>
          <option value="27">2027</option>
          <option value="28">2028</option>
          <option value="29">2029</option>
          <option value="30">2030</option>
          <option value="31">2031</option>
          <option value="32">2032</option>
          <option value="33">2033</option>
        </select>
      </div>
      <div class="dn-field float third cvv">
        <input name="cardcode" type="text" id="CardCode" class="dn-textfield" value="" onkeyup="this.setAttribute('value', this.value);" autocomplete="OFF">
        <span class="dn-title">CVV <span class="dn-star">*</span></span>
      </div>
    </div>
    <div class="clear"></div>
    <hr>
    <div class="dn-head hide-zelle">Additional Information</div>
    <div class="dn-field hide-zelle">
      <textarea name="referral" id="referral" class="dn-textfield" value="" onkeyup="this.setAttribute('value', this.value);"></textarea>
      <span class="dn-title">How Did You Hear About Us?</span>
    </div>
    <div class="dn-field hide-zelle">
      <textarea name="comment" id="comment" class="dn-textfield" value="" onkeyup="this.setAttribute('value', this.value);"></textarea>
      <span class="dn-title">Additional Comments</span>
    </div>
    <div class="dn-field" style="display:none;">
      <input name="receipt" type="checkbox" id="send_receipt" value="True"> <label for="send_receipt">Please mail a receipt to the address above <div class="dn-smalltext">(in addition to the receipt I will receive via email).</div></label>
    </div>
    <div class="dn-onefull" align="center">
      <div class="captcha">
        <script src="https://challenges.cloudflare.com/turnstile/v0/api.js" async="" defer=""></script>
        <div class="cf-turnstile" data-sitekey="0x4AAAAAAADtxmzgoNujOLsS"><iframe src="https://challenges.cloudflare.com/cdn-cgi/challenge-platform/h/b/turnstile/if/ov2/av0/rcv0/0/w403l/0x4AAAAAAADtxmzgoNujOLsS/auto/normal"
            allow="cross-origin-isolated; fullscreen" sandbox="allow-same-origin allow-scripts allow-popups" id="cf-chl-widget-w403l" tabindex="0" title="Widget containing a Cloudflare security challenge"
            style="border: none; overflow: hidden; width: 300px; height: 65px;"></iframe><input type="hidden" name="cf-turnstile-response" id="cf-chl-widget-w403l_response"></div>
      </div>
    </div>
    <div class="dn-onefull" align="center">
    </div>
    <div class="btn-group btn-group-lg btn-group-justified" role="group" aria-label="...">
      <label for="step2" id="back-step2" class="back">
        <div class="button left">Back</div>
      </label>
      <input name="submitBtn" type="submit" value="Donate" class="button right">
    </div>
    <input type="hidden" name="action" value="insert">
    <input type="hidden" name="account_id" value="">
    <input type="hidden" name="invoice" value="">
    <input type="hidden" name="email_customer" value="False">
    <input type="hidden" name="merchant_email" value="">
    <input type="hidden" name="description" value="donate-la">
    <input type="hidden" name="affiliate" value="">
    <input type="hidden" name="trans_id" value="">
    <input type="hidden" name="x_event" value="donate-la">
    <input type="hidden" name="campaign" value="donate-la">
    <input type="hidden" name="prevReferer" value="">
    <input type="hidden" name="debug" value="">
    <input type="hidden" name="test" value="">
    <input type="hidden" name="ccTrack1" id="ccTrack1" value="">
    <input type="hidden" name="ccTrack2" id="ccTrack2" value="">
    <input type="hidden" name="SwiperResponse" id="SwiperResponse" value="">
    <input type="hidden" name="starttime" value="1710021095.7171">
    <div id="dn-account" class="dn-js"> Only enter this field if you were told to do so by a staff member. <input type="text" name="dn-accountID" id="dn-accountID" value="" autocomplete="OFF">
    </div>
    <br><br>
    <div class="clear"></div><br>
    <center> RCCS is a non-profit 501c3 organization. </center>
  </div>
</form>

Text Content

 * Home
 * About RCCS +
    * Our Mission
    * Board & Staff
    * Contact

 * Why +
    * Why Cancer
    * Why RCCS
    * Why You

 * Our Services
 * Events
 * Multimedia
    * Videos

 * Donate

 * Home


 * ABOUT RCCS +
   
   * Our Mission
   * Board & Staff
   * Contact
 * Why +
   * Why Cancer
   * Why RCCS
   * Why You
 * Our Services
 * Events
 * Multimedia
   * Videos
 * Donate

­


DONATE


RCCS HAS HELPED THOUSANDS OF CANCER PATIENTS.



NOW YOU CAN TOO.




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JAVASCRIPT AND THEN RELOAD THIS PAGE IN ORDER TO CONTINUE.

$18,000
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Quarter Year Family Policy Patron
$1,500
One Month Family Policy Patron
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Charge My Card    Bill Me Later
 
YOU WILL BE BILLED LATER



Credit Card Check

--------------------------------------------------------------------------------

Zelle donations can be made via your banking app to quickpay@rccscancer.org.
Account Name *
Account Type Checking Savings

Routing Number *
Account Number *
I hereby authorize this company to debit my bank account through the electronic
Automated Clearing House (ACH) network within one to three business days from
the date of this payment. I am aware that in the event this company is unable to
secure funds from my bank account for this transaction for any reason, including
but not limited to, insufficient funds in my account or insufficient or
inaccurate information I provided when I submitted the electronic payment,
further collection action may be undertaken by this company, including
application of returned check fees to the extent permitted by law. If the
payment is returned by my bank, I am still responsible for making a payment to
this company. I agree to the above ACH terms and conditions

Visa Mastercard American Express Discover Donors Fund OJC Pledger
Card Number *
Exp. Month * 01-January 02-February 03-March 04-April 05-May 06-June 07-July
08-August 09-September 10-October 11-November 12-December
Exp. Year * 2024202520262027202820292030203120322033
CVV *


--------------------------------------------------------------------------------

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Additional Comments
Please mail a receipt to the address above
(in addition to the receipt I will receive via email).


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$600Daniel Uretsky
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$360Mark Colman
$500Aaron Brecher
$600Daniel Uretsky
$1,000Anonymous Anonymous
$360Jonathan Weiss
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$180Susan Nassy
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$1,000Benjamin Rosenberg
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WHO WE ARE

Our Mission
RCCS Israel

SERVICES

Medical Assistance
Financial Assistance
Emotional Assistance

CONTACT

803 Bedford Avenue
Brooklyn NY 11205
P 718-722-2002
F 718-722-4757


RCCS, a recognized 501(c)(3) organization, provides an array of services to
cancer patients and their families, enabling them to secure the best possible
medical care. Notably, among the myriad services offered by RCCS is medical
referrals and support, as well as health insurance premium and medical
subsidies, which provides patients with broader access to global oncologists and
leaders in the cancer treatment field.

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