act.cmmb.org
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74.123.154.22
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Submitted URL: http://act.cmmb.org/site/R?i=kWUyzuQROS1MnB15HzZLXafBNsfLYgrXntcPaLWqP_Yd3tsb8lXg_A
Effective URL: https://act.cmmb.org/site/Donation2;jsessionid=00000000.app30030b?df_id=9302&9302.donation=form1&autologin=true&utm_s...
Submission: On November 17 via api from ES — Scanned from ES
Effective URL: https://act.cmmb.org/site/Donation2;jsessionid=00000000.app30030b?df_id=9302&9302.donation=form1&autologin=true&utm_s...
Submission: On November 17 via api from ES — Scanned from ES
Form analysis 1 forms found in the DOM
Name: process — POST https://act.cmmb.org/site/Donation2
<form name="process" id="ProcessForm" action="https://act.cmmb.org/site/Donation2" method="post" onsubmit="return checkDoubleClick();" data-frequency="one-time" class="ProcessForm--display">
<div class="donation-form-container responsive active">
<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.app30030b?NONCE_TOKEN=E643011DEF50DBAACBE2A4FC994E4061', true);
xmlHttp.send();
}
addOnLoadHandler(testAjax);
//
-->
</script>
<div class="donation-form-content active">
<input type="hidden" name="user_donation_amt" id="user_donation_amt" value="">
<input type="hidden" name="company_min_matching_amt" id="company_min_matching_amt" value="">
<input type="hidden" name="currency_locale" id="currency_locale" value="en_US">
<div class="form-progress-bar">
<div class="progress-bar-step-container progress-bar-step-current">
<div class="progress-bar-step-number-container">1</div>
<div class="progress-bar-step-text-container">Gift & Payment Information</div>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<h1 class="heading_lead-in color--accent-greenOFF">Your gifts save lives.</h1>
<!--Settings:-->
<div id="customization--monthly" style="display: none;">
<!--On this form we want the donation frequency default to One-time.-->
</div>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<!--
Text for donation upsell overlay, edit with WYSIWYG disabled. Adding this reusable into a responsive donation form will cause the overlay to appear upon submission
If you would like to customize default upsell array include the following JSON object here.
-->
<script type="text/javascript">
var upsells = {
'entries': [{
'selectedRangeStart': 25,
'selectedRangeEnd': 39.99,
'suggestedAmount': 5,
'message': ''
}, {
'selectedRangeStart': 40,
'selectedRangeEnd': 59.99,
'suggestedAmount': 10,
'message': ''
}, {
'selectedRangeStart': 60,
'selectedRangeEnd': 74.99,
'suggestedAmount': 12,
'message': ''
}, {
'selectedRangeStart': 75,
'selectedRangeEnd': 99.99,
'suggestedAmount': 15,
'message': ''
}, {
'selectedRangeStart': 100,
'selectedRangeEnd': 124.99,
'suggestedAmount': 20,
'message': ''
}, {
'selectedRangeStart': 125,
'selectedRangeEnd': 149.99,
'suggestedAmount': 25,
'message': ''
}, {
'selectedRangeStart': 150,
'selectedRangeEnd': 199.99,
'suggestedAmount': 30,
'message': ''
}, {
'selectedRangeStart': 200,
'selectedRangeEnd': 249.99,
'suggestedAmount': 40,
'message': ''
}, ]
};
</script>
<div id="upgrade" class="upgrade hidden">
<div class="upgrade__close upgrade__reject">X</div>
<div class="upgrade__title">Thank you for your support!</div>
<p class="upgrade__request">With your help, we can provide health and human dignity to the poorest of the poor. Can you provide continuous support by making a monthly gift of <span class="upgrade__suggested">$<span
class="upgrade__suggested-amount"></span></span>?</p>
<span class="upgrade__message hidden"></span>
<span class="upgrade__selected-amount hidden"></span>
<div class="upgrade__button-container">
<button class="upgrade__button upgrade__button--confirm upgrade__confirm btn--fill-effect" type="button"><span class="btn__text">Yes, start my monthly gift of $<span class="upgrade__suggested-amount"></span>!</span></button>
<br>
<button class="upgrade__button upgrade__button--reject upgrade__reject btn--fill-effect" type="button"><span class="btn__text">No thanks, continue with my one-time gift of $<span class="upgrade__selected-amount"></span></span></button>
</div>
</div>
<div id="upgrade__overlay" class="hidden"></div>
</div>
</div>
<div class="form-row active">
<div class="html-caption-container active">
<div id="monthly-option" class="monthly-option active">
<div class="monthly__radios active">
<div class="monthly__radio-container monthly__radio-container--1 monthly__radio-container--once active">
<input autocomplete="" id="monthly__radio--1" name="monthly__radio" type="radio" value="1">
<label for="monthly__radio--1">Give Once</label>
</div>
<div class="monthly__radio-container monthly__radio-container--2 monthly__radio-container--month">
<input autocomplete="" id="monthly__radio--2" name="monthly__radio" type="radio" value="2">
<label for="monthly__radio--2">Give Monthly</label>
</div>
</div>
<p class="monthly-note"> The best way to help year-round <svg class="monthly-note__arrow" version="1.0" xmlns="http://www.w3.org/2000/svg" viewBox="0 0 1280.000000 1085.000000" preserveAspectRatio="xMidYMid meet">
<g class="shape fill--pms-3295" transform="translate(0.000000,1085.000000) scale(0.100000,-0.100000)" stroke="none">
<path d="M3449 10837 c-20 -8 -49 -23 -65 -35 -59 -43 -3343 -3338 -3360
-3372 -23 -45 -24 -143 -2 -190 8 -19 431 -533 939 -1141 508 -608 1228 -1470
1599 -1915 371 -445 702 -840 734 -878 75 -87 142 -122 218 -113 68 8 126 43
163 97 l30 45 3 1166 2 1166 78 17 c328 69 819 116 1217 116 1668 -1 3233
-594 4555 -1725 1068 -914 1997 -2192 2736 -3768 117 -250 150 -289 256 -303
68 -9 126 12 179 65 74 73 77 95 45 346 -256 1983 -832 3673 -1689 4955 -571
853 -1262 1536 -2077 2052 -924 585 -2011 947 -3190 1063 -297 29 -484 37
-840 37 -443 -1 -800 -24 -1157 -76 l-83 -12 -2 1131 c-3 1030 -4 1133 -20
1160 -21 39 -65 83 -101 102 -41 21 -125 26 -168 10z"></path>
</g>
</svg>
</p>
</div>
<h3 id="heading--donation-amount" class="heading--donation-amount">Donation Amount:</h3>
</div>
</div>
<div id="level_standard_row">
<div class="don-standard-levels form-row">
<div class="levels-label">
</div>
<div id="level_standard_row" class="form-row form-donation-level">
<div class="form-content">
<span class="field-required"></span> <span class="aural-only">Field Is Required</span>
<span class="FormLabelText">Select Gift Amount:</span>
<div class="donation-level-general-ask">
</div>
<div class="donation-levels">
<div class="donation-level-container donation-level-container--standard donation-level-container--one-time">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded17340" value="17340" onclick="evalMatchingGift('$50.00');
updateDonorCoverAmount('$50.00');" class="donation-level__input donation-level__input--radio">
</div>
<label for="level_standardexpanded17340" onclick="" class="donation-level__label">
<div class="donation-level-amount-container"> $50 </div>
</label>
<div class="donation-level-expanded-label"> one-time </div>
<input type="hidden" name="level_standardexpanded17340dynamicAmount" id="level_standardexpanded17340dynamicAmount" value="5000">
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_17340expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container donation-level-container--standard donation-level-container--one-time">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded17341" value="17341" checked="checked" onclick="evalMatchingGift('$100.00');
updateDonorCoverAmount('$100.00');" class="donation-level__input donation-level__input--radio">
</div>
<label for="level_standardexpanded17341" onclick="" class="donation-level__label active donation-level__label--selected">
<div class="donation-level-amount-container"> $100 </div>
</label>
<div class="donation-level-expanded-label"> one-time </div>
<input type="hidden" name="level_standardexpanded17341dynamicAmount" id="level_standardexpanded17341dynamicAmount" value="10000">
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_17341expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container donation-level-container--standard donation-level-container--one-time">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded17342" value="17342" onclick="evalMatchingGift('$250.00');
updateDonorCoverAmount('$250.00');" class="donation-level__input donation-level__input--radio">
</div>
<label for="level_standardexpanded17342" onclick="" class="donation-level__label">
<div class="donation-level-amount-container"> $250 </div>
</label>
<div class="donation-level-expanded-label"> one-time </div>
<input type="hidden" name="level_standardexpanded17342dynamicAmount" id="level_standardexpanded17342dynamicAmount" value="25000">
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_17342expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container donation-level-container--standard donation-level-container--Separator-(Monthly-below.) hidden">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded17331" value="17331" onclick="evalMatchingGift('$0.01');
updateDonorCoverAmount('$0.01');" class="donation-level__input donation-level__input--radio">
</div>
<label for="level_standardexpanded17331" onclick="" class="donation-level__label">
<div class="donation-level-amount-container"> $0.01 </div>
<div class="donation-level-label-container"> Separator (Monthly below.) </div>
</label>
<div class="donation-level-expanded-label"> separator </div>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_17331expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container donation-level-container--standard donation-level-container--monthly hidden">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded17332" value="17332" onclick="evalMatchingGift('$10.00');
updateDonorCoverAmount('$10.00');" class="donation-level__input donation-level__input--radio">
</div>
<label for="level_standardexpanded17332" onclick="" class="donation-level__label">
<div class="donation-level-amount-container"> $10 </div>
</label>
<div class="donation-level-expanded-label"> monthly </div>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_17332expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container donation-level-container--standard donation-level-container--monthly hidden">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded17333" value="17333" onclick="evalMatchingGift('$25.00');
updateDonorCoverAmount('$25.00');" class="donation-level__input donation-level__input--radio">
</div>
<label for="level_standardexpanded17333" onclick="" class="donation-level__label">
<div class="donation-level-amount-container"> $25 </div>
</label>
<div class="donation-level-expanded-label"> monthly </div>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_17333expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container donation-level-container--standard donation-level-container--monthly hidden">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded17334" value="17334" onclick="evalMatchingGift('$35.00');
updateDonorCoverAmount('$35.00');" class="donation-level__input donation-level__input--radio">
</div>
<label for="level_standardexpanded17334" onclick="" class="donation-level__label">
<div class="donation-level-amount-container"> $35 </div>
</label>
<div class="donation-level-expanded-label"> monthly </div>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_17334expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container donation-level-container--user-entered donation-level--other">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded17329" value="17329" onclick="evalMatchingGift(document.getElementById('level_standardexpanded17329amount').value);
updateDonorCoverAmount(document.getElementById('level_standardexpanded17329amount').value);" class="donation-level__input donation-level__input--radio donation-level__input--other">
</div>
<label for="level_standardexpanded17329" onclick="" class="donation-level__label donation-level__label--other">
<div class="donation-level-label-container"> Other </div>
</label>
<div class="donation-level-user-entered js-hidden">
<div id="dollar-prefix" class="dollar-prefix"><input type="text" name="level_standardexpanded17329amount" id="level_standardexpanded17329amount" value="" size="12" maxlength="7"
onfocus="var el = document.getElementById ('level_standardexpanded17329');if (el) el.click(); fire_obs_comp_event('level_standardexpanded17329amount', this, event);evalMatchingGift(value); "
onchange="fire_obs_comp_event('level_standardexpanded17329amount', this, event);evalMatchingGift(value);" onkeyup="fire_obs_comp_event('level_standardexpanded17329amount', this, event);evalMatchingGift(value);"
onblur="fire_obs_comp_event('level_standardexpanded17329amount', this);updateDonorCoverAmount(value);" class="input__overlay donation-level__input donation-level__input--amount"
placeholder="."><a href="#" id="dollar-prefix__other" class="dollar-prefix__other"></a></div><label for="level_standardexpanded17329amount" class="label__overlay"><span class="aural-only">Enter amount</span></label>
</div>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_17329expandedsubmit" value="true">
</div>
</div>
</div>
</div>
<script type="text/javascript">
Y.use("jquery-ui", function(Y) {
jQuery(function() {
// subscribe observables
jQuery('div.donation-level-element-container').find('input[type="radio"]').each(function() {
var syncAction = function(obj) {
if (obj.is(':checked')) {
obj.closest('div.donation-level-container').addClass('selected');
} else {
obj.closest('div.donation-level-container').removeClass('selected');
};
return arguments.callee;
}(jQuery(this));
jQuery(this).click(function() {
jQuery('div.donation-level-container').removeClass('selected');
syncAction(jQuery(this));
});
});
});
});
</script><noscript> </noscript>
</div>
<div class="levels-gift-aid">
</div>
<input type="hidden" name="level_standardsubmit" id="level_standardsubmit" value="true">
<script type="text/javascript">
function updateDonorCoverAmount(gift) {
if (typeof updateAmount !== "undefined") {
updateAmount(gift);
}
};
function evalMatchingGift(gift) {}
</script><noscript> </noscript>
</div>
<div class="donation-level-container-generic-repeat form-input hidden">
<div class="generic-repeat-label-checkbox-container">
<input type="checkbox" name="level_standardauto_repeatname" id="level_standardauto_repeatname" onclick="fire_obs_comp_event('level_standardauto_repeat', this);" onkeypress="fire_obs_comp_event('level_standardauto_repeat', this);">
<label for="level_standardauto_repeatname"> Yes, automatically repeat this gift every month. </label>
</div>
<input type="hidden" name="level_standardauto_repeatsubmit" id="level_standardauto_repeatsubmit" value="true">
</div>
<script type="text/javascript">
// subscribe listeners to make an ajax call to the server to calculate the total amount
Y.use('jquery-noconflict', function() {
var fetchAmountFunc = function() {
// find all the select, textarea, input, etc... and format them into key=val pairs.
var params = jQuery('#level_standard_row :input').serialize();
// parse the path and append the key/value pairs above to the url
var url = 'https://act.cmmb.org/site/Donation2?idb=1243827147&level_standardajaxfetch=true&df_id=9302&mfc_pref=T&9302.donation=form1&level_standardtotalcalculateBtn=true';
var index = url.indexOf("?");
var path = url.substring(0, index);
var args = url.substring(index + 1, url.length);
args += '&' + params;
var recurringGiftTermsContainer = jQuery('#recurring_gift_terms_acceptance_message_container');
if (recurringGiftTermsContainer && recurringGiftTermsContainer.length > 0) {
jQuery.ajax(path, {
data: args,
success: function(data) {
jQuery('#recurring_gift_terms_acceptance_message_container').trigger("recurringTermsChange");
}
});
}
};
jQuery('#level_standard_row :input[type=text]').blur(function() {
fetchAmountFunc();
});
jQuery('#level_standard_row input:checkbox, #level_standard_row input:radio').click(function() {
fetchAmountFunc();
});
jQuery('#level_standard_row select').change(function() {
fetchAmountFunc();
});
// call it on page load
fetchAmountFunc();
});
</script><noscript> </noscript>
</div>
<div class="recurring-gift-terms-acceptance-element-container">
<div id="recurring_gift_terms_acceptance_message_container" class="form-row recurring-gift-terms-acceptance-container"></div>
<script type="text/javascript">
Y.use('jquery-noconflict', function() {
// verify jQuery.live() function by using an optimized selector so that jQuery version doesn't matter
if (typeof jQuery.fn.live == 'undefined' || !(jQuery.isFunction(jQuery.fn.live))) {
jQuery.fn.extend({
live: function(event, callback) {
if (this.selector) {
jQuery(document).on(event, this.selector, callback);
}
}
});
}
// catch the click event when it is triggered to do the Ajax call
jQuery('#recurring_gift_terms_acceptance_message_container').live("recurringTermsChange", function() {
// parse the path and append the key/value pairs above to the url
var url = 'https://act.cmmb.org/site/Donation2?idb=1243827147&df_id=9302&mfc_pref=T&recurring-gift-terms-acceptanceajaxfetch=true&renderRecurringGiftTermsAcceptanceMessage=true&9302.donation=form1';
var index = url.indexOf("?");
var path = url.substring(0, index);
var args = url.substring(index + 1, url.length);
jQuery.ajax(path, {
data: args,
success: function(data) {
jQuery('#recurring_gift_terms_acceptance_message_container').html(data);
}
});
});
});
</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'm making this gift in honor of someone</label>
<input type="hidden" name="tribute_show_honor_fieldssubmit" id="tribute_show_honor_fieldssubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_show_honor_fields', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_show_honor_fields_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('tribute_show_honor_fieldsname')) {
document.getElementById('tribute_show_honor_fieldsname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('tribute_show_honor_fieldsname')) {
return document.getElementById('tribute_show_honor_fieldsname').checked;
}
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_name_row" class="form-row form-text" style="display: none;">
<div class="form-content is-required">
<input type="text" name="tribute_notify_recip_namename" id="tribute_notify_recip_namename" value="" maxlength="70" class="input__overlay" placeholder="."><label for="tribute_notify_recip_namename"
class="label__overlay label--required parent-leng-false"><span class="field-required"></span>This gift is being made in honor of</label>
<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>
<input type="hidden" name="channelhidden" id="channelhidden" value="Email">
<input type="hidden" name="page_descriptionhidden" id="page_descriptionhidden" value="UPDATE: "The support translates directly into lives saved." ">
<input type="hidden" name="page_titlehidden" id="page_titlehidden" value="UPDATE: "The support translates directly into lives saved." ">
<input type="hidden" name="gl_countryhidden" id="gl_countryhidden" value="U.S Direct Response | 918">
<input type="hidden" name="re_packagehidden" id="re_packagehidden" value="Email">
<input type="hidden" name="gl_donorhidden" id="gl_donorhidden" value="Unrestricted | 100">
<input type="hidden" name="re_campaignhidden" id="re_campaignhidden" value="4010">
<input type="hidden" name="re_appealhidden" id="re_appealhidden" value="Z23">
<input type="hidden" name="re_fundhidden" id="re_fundhidden" value="900">
<div id="send_ecard_row" class="form-row form-checkbox">
<div class="form-content">
<span class="check-box-form-label-text">Would you like to send an ecard along with this gift?</span>
<input type="checkbox" name="send_ecardname" id="send_ecardname" onclick="fire_obs_comp_event('send_ecard', this);">
<label for="send_ecardname">This is a gift and I would like to send an eCard</label>
<input type="hidden" name="send_ecardsubmit" id="send_ecardsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('send_ecard', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('send_ecard_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('send_ecardname')) {
document.getElementById('send_ecardname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('send_ecardname')) {
return document.getElementById('send_ecardname').checked;
}
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
</div>
</div>
<div id="ecard_send_date_row" class="form-row form-date" style="display: none;"><input id="ecard_send_date_toggle" name="ecard_send_date_toggle" type="checkbox"><label for="ecard_send_date_toggle">Send message later</label>
<div class="form-content" style="display: none;">
<label for="ecard_send_date_MONTH">
<span class="label-text">Send eCard on this date:</span><span class="aural-only">Select month of credit card</span>
</label>
<label for="ecard_send_date_YEAR"><span class="aural-only">Select Expiration Year</span></label>
<div class="date-input-container">
<label for="ecard_send_date_MONTH"><span style="display:none;">Month</span></label>
<label for="ecard_send_date_DAY"><span style="display:none;">Day</span></label>
<label for="ecard_send_date_YEAR"><span style="display:none;">Year</span></label>
<select name="ecard_send_date_MONTH" id="ecard_send_date_MONTH" title="Month">
<option value="1">Jan</option>
<option value="2">Feb</option>
<option value="3">Mar</option>
<option value="4">Apr</option>
<option value="5">May</option>
<option value="6">Jun</option>
<option value="7">Jul</option>
<option value="8">Aug</option>
<option value="9">Sep</option>
<option value="10">Oct</option>
<option value="11" selected="selected">Nov</option>
<option value="12">Dec</option>
</select>
<select name="ecard_send_date_DAY" id="ecard_send_date_DAY" title="Day">
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17" selected="selected">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select>
<select name="ecard_send_date_YEAR" id="ecard_send_date_YEAR" title="Year">
<option value="2033">2033</option>
<option value="2032">2032</option>
<option value="2031">2031</option>
<option value="2030">2030</option>
<option value="2029">2029</option>
<option value="2028">2028</option>
<option value="2027">2027</option>
<option value="2026">2026</option>
<option value="2025">2025</option>
<option value="2024">2024</option>
<option value="2023" selected="selected">2023</option>
</select>
</div>
<input type="hidden" name="ecard_send_datesubmit" id="ecard_send_datesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('ecard_send_date', 'input');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('ecard_send_date_row', _display);
disable_submit_flag('ecard_send_datesubmit', _hidden);
}
comp.disable = function(_disabled) {
disable_element('ecard_send_date_MONTH', _disabled);
disable_element('ecard_send_date_DAY', _disabled);
disable_element('ecard_send_date_YEAR', _disabled);
disable_element('ecard_send_date_HOUR12', _disabled);
disable_element('ecard_send_date_HOUR24', _disabled); //For UK, 24 hour clock used
disable_element('ecard_send_date_MINUTE', _disabled);
disable_element('ecard_send_date_AMPM', _disabled);
}
</script><noscript> </noscript>
</div>
</div>
<div id="ecard_recpients_row" class="form-row form-text" style="display: none;">
<div class="form-content is-required">
<label for="ecard_recpientsname" class="label--required parent-leng-false"><span class="field-required"></span>Recipient email addresses:</label>
<p class="hint">Enter multiple addresses on separate lines or separate them with commas. (Note: We respect your privacy and do not send unsolicited email to the addresses you enter. For further information, see our Privacy Policy)</p>
<textarea cols="60" rows="4" name="ecard_recpientsname" id="ecard_recpientsname"></textarea>
<input type="hidden" name="ecard_recpientssubmit" id="ecard_recpientssubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('ecard_recpients', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('ecard_recpients_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="select_grid_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<label for="select_gridname">Choose an eCard design:</label>
<input type="hidden" name="stationery_layout_chooser" id="stationery_layout_chooser" value="true">
<div class="layout-chooser-container clearfix">
<div class="layout-choice-thumbnail-container">
<label class="layout-choice-thumbnail-label js-active" for="stationery_layout_id_1441">
<img src="https://secure3.convio.net/cmmbin/images/content/pagebuilder/A_Gift_for_You_th_compressed.jpg" alt="Gift for You ecard" border="0" class="image-checked">
<div class="image-checked__shadow"></div>
</label>
<input type="radio" name="stationery_layout_id" id="stationery_layout_id_1441" value="1441" checked="checked">
</div>
<div class="layout-choice-thumbnail-container">
<label class="layout-choice-thumbnail-label" for="stationery_layout_id_1383">
<img src="https://secure3.convio.net/cmmbin/images/content/pagebuilder/child_ecard.png" alt="In Honor of eCard - Child" border="0">
<div class="image-checked__shadow"></div>
</label>
<input type="radio" name="stationery_layout_id" id="stationery_layout_id_1383" value="1383">
</div>
<div class="layout-choice-thumbnail-container">
<label class="layout-choice-thumbnail-label" for="stationery_layout_id_1382">
<img src="https://secure3.convio.net/cmmbin/images/content/pagebuilder/EcardGen.png" alt="In Honor of eCard - Flowers" border="0">
<div class="image-checked__shadow"></div>
</label>
<input type="radio" name="stationery_layout_id" id="stationery_layout_id_1382" value="1382">
</div>
<div class="layout-choice-thumbnail-container">
<label class="layout-choice-thumbnail-label" for="stationery_layout_id_1381">
<img src="https://secure3.convio.net/cmmbin/images/content/pagebuilder/EcardMemory.png" alt="In Memory of eCard" border="0">
<div class="image-checked__shadow"></div>
</label>
<input type="radio" name="stationery_layout_id" id="stationery_layout_id_1381" value="1381">
</div>
</div>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('select_grid', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('select_grid_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script><noscript> </noscript>
<input type="hidden" name="select_gridsubmit" id="select_gridsubmit" value="true">
</div>
</div>
<div id="tribute_ecard_subject_row" class="form-row form-text" style="display: none;">
<div class="form-content is-required">
<input type="text" name="tribute_ecard_subjectname" id="tribute_ecard_subjectname" value="" maxlength="50" class="input__overlay" placeholder="."><label for="tribute_ecard_subjectname"
class="label__overlay label--required parent-leng-false"><span class="field-required"></span>eCard Subject:</label>
<input type="hidden" name="tribute_ecard_subjectsubmit" id="tribute_ecard_subjectsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_ecard_subject', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_ecard_subject_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_ecard_message_row" class="form-row form-text" style="display: none;">
<div class="form-content is-required">
<label for="tribute_ecard_messagename" class="label--required parent-leng-false"><span class="field-required"></span>eCard Message:</label>
<textarea cols="60" rows="4" name="tribute_ecard_messagename" id="tribute_ecard_messagename"></textarea>
<input type="hidden" name="tribute_ecard_messagesubmit" id="tribute_ecard_messagesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_ecard_message', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_ecard_message_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="e_card_copy_sender_row" class="form-row form-checkbox" style="display: none;">
<div class="form-content">
<input type="checkbox" name="e_card_copy_sendername" id="e_card_copy_sendername" onclick="fire_obs_comp_event('e_card_copy_sender', this);">
<label for="e_card_copy_sendername">Yes, send me a copy of the eCard.</label>
<input type="hidden" name="e_card_copy_sendersubmit" id="e_card_copy_sendersubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('e_card_copy_sender', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('e_card_copy_sender_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('e_card_copy_sendername')) {
document.getElementById('e_card_copy_sendername').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('e_card_copy_sendername')) {
return document.getElementById('e_card_copy_sendername').checked;
}
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
</div>
</div>
<div id="preview_button_row" class="form-row" style="display: none;">
<label for="preview_buttonname">Enable pop-ups on your browser then click Ecard Preview to see how it will look.</label>
<div id="null_row" class="form-row form-button">
<div class="form-content">
<button class="step-button action-button btn--fill-effect" type="submit" name="nullbtn" id="nullbtn" value="eCard Preview" title="Reloads page. "><span class="btn__text"> eCard Preview </span></button>
<input type="hidden" name="nullsubmit" id="nullsubmit" value="true">
<button type="button" class="step-button reset-button">Reset eCard</button>
</div>
</div>
<input type="hidden" name="preview_buttonsubmit" id="preview_buttonsubmit" value="true">
</div>
<div class="form-row">
<div class="html-caption-container">
<script src="https://code.jquery.com/jquery-1.9.1.js"></script>
<script>
$(function() {
$('#send_ecardname').change(function() {
$('#ecard_send_date_row').toggle(this.checked);
$('#ecard_recpients_row').toggle(this.checked);
$('#select_grid_row').toggle(this.checked);
$('#tribute_ecard_subject_row').toggle(this.checked);
$('#tribute_ecard_message_row').toggle(this.checked);
$('#e_card_copy_sender_row').toggle(this.checked);
$('#preview_button_row').toggle(this.checked);
}).change(); //ensure visible state matches initially
});
</script>
</div>
</div>
<h2 class="section-header-container"> Donor and Billing Information: </h2>
<div id="billing_first_name_row" class="form-row form-text">
<div class="form-content is-required">
<input type="text" name="billing_first_namename" id="billing_first_namename" value="" maxlength="50" class="input__overlay" placeholder="."><label for="billing_first_namename" class="label__overlay label--required parent-leng-false"><span
class="field-required"></span>First Name</label>
<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 is-required">
<input type="text" name="billing_last_namename" id="billing_last_namename" value="" maxlength="50" class="input__overlay" placeholder="."><label for="billing_last_namename" class="label__overlay label--required parent-leng-false"><span
class="field-required"></span>Last Name</label>
<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_country_row" class="form-row form-selectlist">
<div class="form-content">
<label class="FormLabel" for="billing_addr_country">Country</label>
<select name="billing_addr_country" id="billing_addr_country" size="1" onchange="fire_obs_comp_event('billing_addr_country', this)">
<option></option>
<option selected="selected" value="United States">United States</option>
<option value="Afghanistan">Afghanistan</option>
<option value="Aland Islands">Aland Islands</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antarctica">Antarctica</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivarian Republic of Venezuela">Bolivarian Republic of Venezuela</option>
<option value="Bonaire, Sint Eustatios and Saba">Bonaire, Sint Eustatios and Saba</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet Island">Bouvet Island</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
<option value="Brunei Darussalam">Brunei Darussalam</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cape Verde">Cape Verde</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Cote D'Ivoire">Cote D'Ivoire</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Curacao">Curacao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</option>
<option value="Democratic People's Republic of Korea">Democratic People's Republic of Korea</option>
<option value="The Democratic Republic of the Congo">The Democratic Republic of the Congo</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Falkland Islands (Malvinas)">Falkland Islands (Malvinas)</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Federated States of Micronesia">Federated States of Micronesia</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="The Former Yugoslav Republic of Macedonia">The Former Yugoslav Republic of Macedonia</option>
<option value="France">France</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern Territories">French Southern Territories</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guernsey">Guernsey</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option>
<option value="Holy See (Vatican City State)">Holy See (Vatican City State)</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Islamic Republic of Iran">Islamic Republic of Iran</option>
<option value="Isle of Man">Isle of Man</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jersey">Jersey</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macao">Macao</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montenegro">Montenegro</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestinian Territory, Occupied">Palestinian Territory, Occupied</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Pitcairn">Pitcairn</option>
<option value="Plurinational State of Bolivia">Plurinational State of Bolivia</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Republic of Korea">Republic of Korea</option>
<option value="Republic of Moldova">Republic of Moldova</option>
<option value="Reunion">Reunion</option>
<option value="Romania">Romania</option>
<option value="Russian Federation">Russian Federation</option>
<option value="Rwanda">Rwanda</option>
<option value="Saint Barthelemy">Saint Barthelemy</option>
<option value="Saint Helena, Ascension and Tristan da Cunha">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Martin (French)">Saint Martin (French)</option>
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia">Serbia</option>
<option value="Seychelles">Seychelles</option>
<option value="S. Georgia & S. Sandwich Isls.">S. Georgia & S. Sandwich Isls.</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Sint Maarten (Dutch)">Sint Maarten (Dutch)</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="South Sudan">South Sudan</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
<option value="Swaziland">Swaziland</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syrian Arab Republic">Syrian Arab Republic</option>
<option value="Taiwan, Province of China">Taiwan, Province of China</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Thailand">Thailand</option>
<option value="Timor-Leste">Timor-Leste</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkey">Turkey</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="United Republic of Tanzania">United Republic of Tanzania</option>
<option value="Uruguay">Uruguay</option>
<option value="USA Minor Outlying Islands">USA Minor Outlying Islands</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Viet Nam">Viet Nam</option>
<option value="Virgin Islands (British)">Virgin Islands (British)</option>
<option value="Virgin Islands (USA)">Virgin Islands (USA)</option>
<option value="Wallis and Futuna">Wallis and Futuna</option>
<option value="Western Sahara">Western Sahara</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('billing_addr_country', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_country_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="billing_addr_countrysubmit" id="billing_addr_countrysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_country', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_country_row', _display);
this.disable_submit_flag(_hidden);
}
function billing_addr_country_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('billing_addr_country', src);
}
}
var el = document.getElementById('billing_addr_country');
if (el) {
Utils.addEvent(el, 'change', billing_addr_country_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_street1_row" class="form-row form-text">
<div class="form-content is-required">
<input type="text" name="billing_addr_street1name" id="billing_addr_street1name" value="" maxlength="50" class="input__overlay" placeholder="."><label for="billing_addr_street1name"
class="label__overlay label--required parent-leng-false"><span class="field-required"></span>Street 1</label>
<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">
<input type="text" name="billing_addr_street2name" id="billing_addr_street2name" value="" maxlength="50" class="input__overlay" placeholder="."><label for="billing_addr_street2name" class="label__overlay">Street 2</label>
<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 is-required">
<input type="text" name="billing_addr_cityname" id="billing_addr_cityname" value="" maxlength="50" class="input__overlay" placeholder="."><label for="billing_addr_cityname" class="label__overlay label--required parent-leng-false"><span
class="field-required"></span>City</label>
<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 class="locale-row-container billing__locale">
<div id="billing_addr_state_row" class="form-row form-selectlist">
<div class="form-content is-required">
<label class="FormLabel label--required parent-leng-false" for="billing_addr_state"><span class="field-required"></span>State</label><label for="intl_billing_state_province_input" class="hidden"><span
class="field-required"></span>State/Province</label>
<select name="billing_addr_state" id="billing_addr_state" size="1" onchange="fire_obs_comp_event('billing_addr_state', this)" initial-value="">
<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><input type="text" name="intl_billing_state_province_input" id="intl_billing_state_province_input" value="" maxlength="255" placeholder="." data-validation-optional="true" class="hidden">
<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 is-required">
<input type="tel" name="billing_addr_zipname" id="billing_addr_zipname" value="" maxlength="10" class="input__overlay" placeholder="." required="required" data-mask="00000-0000" pattern="^\d{5}(?:[-]\d{4})?$"
data-validation-regexp="^\d{5}(?:[-]\d{4})?$" autocomplete="off"><label for="billing_addr_zipname" class="label__overlay label--required parent-leng-false"><span class="field-required"></span>Zip/Postal Code</label>
<input type="hidden" name="billing_addr_zipsubmit" id="billing_addr_zipsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_zip', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_zip_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
</div>
<div class="custom-field-container form-row js-hidden hidden">
<div class="form-content">
<div class="form-input-label-block">
<label for="intl_billing_state_province_input">State/Province</label>
</div>
<input type="hidden" name="intl_billing_state_provincesubmit" id="intl_billing_state_provincesubmit" value="" data-validation-optional="true">
</div>
</div>
<div id="donor_email_address_row" class="form-row form-text">
<div class="form-content is-required">
<input type="text" name="donor_email_addressname" id="donor_email_addressname" value="" maxlength="255" class="input__overlay" placeholder="."><label for="donor_email_addressname"
class="label__overlay label--required parent-leng-false"><span class="field-required"></span>Email Address:</label>
<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 id="donor_phone_row" class="form-row form-text">
<div class="form-content">
<input type="text" name="donor_phonename" id="donor_phonename" value="" maxlength="50" class="input__overlay" placeholder="."><label for="donor_phonename" class="label__overlay">Phone Number (XXX-XXX-XXXX):</label>
<input type="hidden" name="donor_phonesubmit" id="donor_phonesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_phone', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_phone_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div 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="hidden" name="donor_email_opt_inname" id="donor_email_opt_inname" value="implicit">
<span class="auto-opt-in-warning-message">If you donate and have not already registered, you will receive periodic updates and communications from CMMB.</span>
<script type="text/javascript">
var comp = new ObservableComponent('donor_email_opt_in', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_email_opt_in_Row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('donor_email_opt_inname')) {
document.getElementById('donor_email_opt_inname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('donor_email_opt_inname')) return document.getElementById('donor_email_opt_inname').checked;
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
<input type="hidden" name="donor_email_opt_insubmit" id="donor_email_opt_insubmit" value="true">
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<div class="remember-me__privacy-policy">
<div class="privacy-statement">If you donate and have not already registered, you will receive periodic updates and communications from CMMB.
<a class="privacy-statement__link" href="https://cmmb.org/privacy-policy/" target="_blank">View privacy policy.</a></div>
</div>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<h3>Payment Information:</h3>
</div>
</div>
<div class="payment-type-element-container">
<div class="payment-type-selection-container payment-field-container">
<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">
<h3>Select a Payment Type:</h3>
<span class="internal-payment"><span class="payment-type-option selected"><input type="radio" name="responsive_payment_typepay_typeradio" id="responsive_payment_typepay_typeradiocredit" value="credit" checked="checked"
onclick="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" onkeypress="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);"><label for="responsive_payment_typepay_typeradiocredit">Credit
Card</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);"><label for="responsive_payment_typepay_typeradioach">Bank
Account</label>
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_typepay_typeradio', 'name');
</script><noscript> </noscript>
</span><span class="payment-type-option payment-type-option--paypal"><input type="radio" name="responsive_payment_typepay_typeradio" id="responsive_payment_typepay_typeradiopaypal" value="paypal"
onclick="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" onkeypress="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);"><label
for="responsive_payment_typepay_typeradiopaypal"><a href="javascript:void(0);" class="payment-type-label"> <img src="https://secure3.convio.net/nsala/images/payment/paypal-logo.png" alt="Pay with Paypal" class="paypal-logo"></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>
</div>
<input type="hidden" name="responsive_payment_typepay_typeradiosubmit" id="responsive_payment_typepay_typeradiosubmit" value="true">
<script type="text/javascript">
Y.use("jquery-ui", function(Y) {
jQuery(function() {
// subscribe observable for payment type options
jQuery('.payment-type-option').each(function() {
var syncAction = function(obj) {
if (obj.hasClass('selected')) {
var radioGroupName = obj.find('input').attr('name');
obj.find('input').prop('checked', true);
fire_obs_comp_event(radioGroupName, obj.find('input').get());
}
return arguments.callee;
}(jQuery(this));
jQuery(this).click(function() {
jQuery('.payment-type-option').removeClass('selected');
jQuery(this).addClass('selected');
syncAction(jQuery(this));
var selectedValue = jQuery(this).find('input').val();
if (selectedValue == 'paypal' || selectedValue == 'amazon') {
// open up a boxinator dialog
jQuery(document).trigger('redirect-external');
jQuery('#btn_next').click();
}
});
});
});
});
var comp = new ObservableRadioComponent('responsive_payment_typepay_typeradio', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typepay_typeradio_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
</div>
<div id="payment_cc_container" class="payment-field-container">
<h3>Credit Card Information:</h3>
<div id="responsive_payment_typecc_type_row" class="form-row form-radio-array">
<div class="form-content">
<fieldset>
<legend>Credit Card Type:</legend>
<ul class="radio-array-list">
<li class="tender-row ">
<img src="../images/discovercard_sm.gif" alt="Discover" name="responsive_payment_typecc_type_Discover" id="responsive_payment_typecc_type_Discover">
</li>
<li class="tender-row ">
<img src="../images/amex_small.gif" alt="American Express" name="responsive_payment_typecc_type_American_Express" id="responsive_payment_typecc_type_American_Express">
</li>
<li class="tender-row ">
<img src="../images/mastercd_small.gif" alt="MasterCard" name="responsive_payment_typecc_type_MasterCard" id="responsive_payment_typecc_type_MasterCard">
</li>
<li class="tender-row ">
<img src="../images/visa_small.gif" alt="Visa" name="responsive_payment_typecc_type_Visa" id="responsive_payment_typecc_type_Visa">
</li>
</ul>
</fieldset>
<input type="hidden" name="responsive_payment_typecc_typesubmit" id="responsive_payment_typecc_typesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_typecc_type', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_type_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typecc_number_row" class="form-row form-text">
<div class="form-content is-required">
<input type="text" name="responsive_payment_typecc_numbername" id="responsive_payment_typecc_numbername" value="" maxlength="22" autocomplete="cc-number" class="input__overlay" placeholder="."><label
for="responsive_payment_typecc_numbername" class="label__overlay label--required parent-leng-false"><span class="field-required"></span>Credit Card Number:</label>
<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 class="cc-info-container js-added">
<div id="responsive_payment_typecc_exp_date_row" class="form-row form-date">
<div class="form-content is-required">
<label for="responsive_payment_typecc_exp_date_MONTH">
<span class="label-text label--required parent-leng-false"><span class="field-required"></span>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">
<div class="cc-date__container">
<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="2023" selected="selected">2023</option>
<option value="2024">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
<option value="2027">2027</option>
<option value="2028">2028</option>
<option value="2029">2029</option>
<option value="2030">2030</option>
<option value="2031">2031</option>
<option value="2032">2032</option>
<option value="2033">2033</option>
</select>
</div>
</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>
</div>
<div id="payment_bank_container" class="payment-field-container" style="display: none;">
<h3>Bank Account Information:</h3>
<div id="responsive_payment_typerouting_number_row" class="form-row form-text">
<div class="form-content is-required">
<a href="http://help.convio.net/site/PageServer?s_site=cmmbin&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" class="input__overlay" placeholder="."><label for="responsive_payment_typerouting_numbername" class="label__overlay label--required parent-leng-false"><span class="field-required"></span>Bank Routing Number:</label>
<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 is-required">
<input type="text" name="responsive_payment_typebank_accountname" id="responsive_payment_typebank_accountname" value="" maxlength="20" autocomplete="off" class="input__overlay" placeholder="."><label
for="responsive_payment_typebank_accountname" class="label__overlay label--required parent-leng-false"><span class="field-required"></span>Bank Account Number:</label>
<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 is-required">
<input type="text" name="responsive_payment_typeverify_bank_accountname" id="responsive_payment_typeverify_bank_accountname" value="" maxlength="20" autocomplete="off" class="input__overlay" placeholder="."><label
for="responsive_payment_typeverify_bank_accountname" class="label__overlay label--required parent-leng-false"><span class="field-required"></span>Verify Bank Account Number:</label>
<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="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="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 is-required">
<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" class="label--required parent-leng-false"><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="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>
<div class="custom-field-container form-row ">
<div class="form-content">
<div class="form-input-label-block">
<label for="donor_pays_processing_fee_dropdown">Would you like your complete donation to go to CMMB?</label>
</div>
<fieldset>
<input type="checkbox" name="donor_pays_processing_fee_radio" id="donor_pays_processing_fee_radio" value="true">
<label class="custom-element-checkbox-label" for="donor_pays_processing_fee_radio">I want 100% to go to CMMB. Please increase my donation amount by 3% to cover credit card transaction fees<span class="cover-fees__end">.</span><span
id="cover-fees__summary" class="cover-fees__summary hidden">, for a total of <strong class="cover-fees__total"></strong>.</span></label>
</fieldset>
<input type="hidden" name="donor_pays_processing_feesubmit" id="donor_pays_processing_feesubmit" value="true">
</div>
</div>
<input type="hidden" name="donation_amount_originalhidden" id="donation_amount_originalhidden" value="100">
<input type="hidden" name="donation_feeshidden" id="donation_feeshidden" value="0">
<div class="button-container clearfix">
<div class="button-sub-container">
<button class="step-button action-button finish-step btn--fill-effect" type="submit" id="pstep_finish" name="pstep_finish" value="Process Donation"><span class="btn__text">Donate $100.00</span></button>
</div>
</div>
<input type="hidden" name="idb" id="idb" value="1243827147">
<input type="hidden" name="df_id" id="df_id" value="9302">
<input type="hidden" name="mfc_pref" id="mfc_pref" value="T">
<div class="form-row">
<div class="html-caption-container">
<script type="text/javascript">
<!-- start paste
-->
<!-- end paste -->
</script>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
</div>
</div>
</div>
<input type="hidden" name="9302.donation" id="9302.donation" value="form1">
</div>
<script type="text/javascript">
var submitted = false;
function checkDoubleClick() {
var elCheck = '';
if (elCheck == 'el') {
alert('Form submission is not enabled when previewing an individual data element.');
return false;
} else if (submitted) {
alert('You have already submitted this payment. Please wait....');
return false;
} else {
submitted = true;
return true;
}
}
</script><noscript> </noscript>
</form>Text Content
CMMB
CMMB
Healthier Lives Worldwide
HELP FAMILIES IN CRISIS
When innocents desperately call for help, it is our responsibility to answer.
When there are troubles around the world (in Sudan, Gaza, Ukraine, Afghanistan,
Armenia, Haiti, and many others) we strategically work directly on the ground or
through trusted partners like Mother of Mercy Hospital, partners who are doing
lifesaving work and urgently need your support.
Your gift provides medicines and other critical support to people affected by
violent crises, extreme poverty, and health inequity around the world. Please
don’t wait, give today.
THANK YOU, !
We are deeply grateful for your generosity and support of CMMB. Your gift makes
a big difference in the lives of women and children where we work, and helps
them to create a healthier future for themselves and their families.
Once again, thank you for your support.
Your gift will be used by CMMB to provide lifesaving support where our resources
will be most effectively allocated.
1
Gift & Payment Information
YOUR GIFTS SAVE LIVES.
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Thank you for your support!
With your help, we can provide health and human dignity to the poorest of the
poor. Can you provide continuous support by making a monthly gift of $?
Yes, start my monthly gift of $!
No thanks, continue with my one-time gift of $
Give Once
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DONATION AMOUNT:
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one-time
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one-time
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monthly
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monthly
$35
monthly
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We respect your privacy and do not send unsolicited email to the addresses you
enter. For further information, see our Privacy Policy)
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Enable pop-ups on your browser then click Ecard Preview to see how it will look.
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DONOR AND BILLING INFORMATION:
First Name
Last Name
Country United States Afghanistan Aland Islands Albania Algeria American Samoa
Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba
Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium
Belize Benin Bermuda Bhutan Bolivarian Republic of Venezuela Bonaire, Sint
Eustatios and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British
Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia
Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile
China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook
Islands Costa Rica Cote D'Ivoire Croatia Cuba Curacao Cyprus Czech Republic
Democratic People's Republic of Korea The Democratic Republic of the Congo
Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador
Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe
Islands Federated States of Micronesia Fiji Finland The Former Yugoslav Republic
of Macedonia France French Guiana French Polynesia French Southern Territories
Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe
Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and
McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary
Iceland India Indonesia Iraq Ireland Islamic Republic of Iran Isle of Man Israel
Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan
Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya
Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives
Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico
Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru
Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk
Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian
Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn
Plurinational State of Bolivia Poland Portugal Puerto Rico Qatar Republic of
Korea Republic of Moldova Reunion Romania Russian Federation Rwanda Saint
Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis
Saint Lucia Saint Martin (French) Saint Pierre and Miquelon Saint Vincent and
the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal
Serbia Seychelles S. Georgia & S. Sandwich Isls. Sierra Leone Singapore Sint
Maarten (Dutch) Slovakia Slovenia Solomon Islands Somalia South Africa South
Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden
Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Thailand
Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan
Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United
Kingdom United Republic of Tanzania Uruguay USA Minor Outlying Islands
Uzbekistan Vanuatu Viet Nam Virgin Islands (British) Virgin Islands (USA) Wallis
and Futuna Western Sahara Yemen Zambia Zimbabwe
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City
StateState/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
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If you donate and have not already registered, you will receive periodic updates
and communications from CMMB.
If you donate and have not already registered, you will receive periodic updates
and communications from CMMB. View privacy policy.
PAYMENT INFORMATION:
SELECT A PAYMENT TYPE:
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 2023 2024 2025 2026 2027 2028 2029 2030 2031
2032 2033
BANK ACCOUNT INFORMATION:
What is this? Bank Routing Number:
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
Would you like your complete donation to go to CMMB?
I want 100% to go to CMMB. Please increase my donation amount by 3% to cover
credit card transaction fees., for a total of .
Donate $100.00
Pay with
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*Select a Payment Type:
*Required field
HEALTHIER LIVES WORLDWIDE
Contact Us | Privacy Policy
98% of your donation supports programs for women, children and their
communities.
© Catholic Medical Mission Board Inc.
Catholic Medical Mission Board Inc. is an IRS Section 501 (c) (3) organization.
Our Federal Tax ID (EIN) is 13-5602319.
© Catholic Medical Mission Board Inc.
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