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Submitted URL: http://click.content.jdrf.org/?qs=b205641e4d28e085fd7d2987efe0a256697d2aff094b194ae08c18cc03da21f0b0d227c7eae4f73a3dc7824de58f...
Effective URL: https://www2.jdrf.org/site/Donation2?22769.donation=form1&df_id=22769&mfc_pref=T&utm_source=REseries1DF&utm_medium=ema...
Submission: On October 13 via api from US — Scanned from DE
Effective URL: https://www2.jdrf.org/site/Donation2?22769.donation=form1&df_id=22769&mfc_pref=T&utm_source=REseries1DF&utm_medium=ema...
Submission: On October 13 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST https://www2.jdrf.org/site/CRDonationAPI
<form action="https://www2.jdrf.org/site/CRDonationAPI" method="post" class="donation-form js--donation-form" id="donForm22769" novalidate=""
data-success-redirect="SPageServer?pagename=bsd_spirit_donation_thanks&df_id=22769&s_don_form_logo_variant=" data-parsley-excluded="input[type=button], input[type=submit], input[type=reset], input[type=hidden], [disabled], :hidden">
<input type="hidden" name="donation_form_auth" value="LHNSFNJqcearE0EaMYCpvXIRAMG3_zaMpXX8Ln62H3YeQdzP5KLvzERbF_96snHreKIn18ObjQeGpBSLCWRCuy3H7UUHnAtYcVntQqY">
<!-- Hidden inputs - API common fields -->
<input id="method" class="js--form-method" name="method" type="hidden" value="donate">
<!-- Hidden inputs - processing options -->
<input id="validate" name="validate" type="hidden" value="true">
<input id="source" name="source" type="hidden" value="national_5000">
<input id="subsource" name="sub_source" type="hidden" value="Re-Engagement Welcome Series - Email 1_https://www2.jdrf.org/site/Donation2?22769.donation=form1&df_id=22769&mfc_pref=T&utm_source=REseries1DF&utm_medium=email">
<!-- Hidden inputs - form_id and redirect URLs-->
<noscript>
<input id="error_redirect" name="error_redirect" type="hidden"
value="https://www2.jdrf.org/site/Donation2?22769.donation=form1&df_id=22769&mfc_pref=T&utm_source=REseries1DF&utm_medium=email&utm_source=national_5000&utm_medium=email&utm_campaign=Re-Engagement+Welcome+Series+-+Email+1&utm_content=https%3a%2f%2fwww2.jdrf.org%2fsite%2fDonation2%3f22769.donation%3dform1%26df_id%3d22769%26mfc_pref%3dT%26utm_source%3dREseries1DF%26utm_medium%3demail&s_src=national_5000&s_subsrc=Re-Engagement+Welcome+Series+-+Email+1_https%3a%2f%2fwww2.jdrf.org%2fsite%2fDonation2%3f22769.donation%3dform1%26df_id%3d22769%26mfc_pref%3dT%26utm_source%3dREseries1DF%26utm_medium%3demail&error=1">
<input id="success_redirect" name="success_redirect" type="hidden" value="SPageServer?pagename=bsd_spirit_donation_thanks&df_id=22769&s_don_form_logo_variant=">
</noscript>
<input id="finish_success_redirect" name="finish_success_redirect" type="hidden" value="SPageServer?pagename=bsd_spirit_donation_thanks&df_id=22769&s_don_form_logo_variant=">
<input id="finish_error_redirect" name="finish_error_redirect" type="hidden"
value="https://www2.jdrf.org/site/Donation2?22769.donation=form1&df_id=22769&mfc_pref=T&utm_source=REseries1DF&utm_medium=email&utm_source=national_5000&utm_medium=email&utm_campaign=Re-Engagement+Welcome+Series+-+Email+1&utm_content=https%3a%2f%2fwww2.jdrf.org%2fsite%2fDonation2%3f22769.donation%3dform1%26df_id%3d22769%26mfc_pref%3dT%26utm_source%3dREseries1DF%26utm_medium%3demail&s_src=national_5000&s_subsrc=Re-Engagement+Welcome+Series+-+Email+1_https%3a%2f%2fwww2.jdrf.org%2fsite%2fDonation2%3f22769.donation%3dform1%26df_id%3d22769%26mfc_pref%3dT%26utm_source%3dREseries1DF%26utm_medium%3demail&paypal_error=true&paypal_error_code=${errorResponse/code}&paypal_error_message=${errorResponse/message}">
<input id="form_id" name="form_id" type="hidden" value="22769">
<header class="form__header">
<div class="spirit-row">
<div class="spirit-col-12">
<div class="js--donation-form-intro-container">
<h1 class="spirit-h1">Support Life-Changing T1D Breakthroughs</h1>
<p class="spirit-body-text-m">Your gift today will help us continue our work toward the next breakthrough, toward a better life for everyone living with T1D, and toward a world without this disease. Thank you!</p>
</div>
</div>
</div>
</header>
<div class="form__fields">
<div class="form__error spirit-d-none">
<div class="spirit-form__message spirit-form__message--error">
<div class="spirit-form__message-icon-wrap"><svg aria-label="alert-circle" class="spirit-icon spirit-form__message-icon" aria-hidden="true">
<use xlink:href="#alert-circle"></use>
</svg></div>
<div class="spirit-form__message-text form-errors-message"> </div>
</div>
</div>
<h4 class="spirit-h4">Frequency</h4>
<div class="spirit-row row-radios js--form-level-occurance">
<div class="spirit-col-md-6 spirit-col-md-auto form-item-radio one-time-gift-radio">
<div class="spirit-button spirit-button--toggle"><label class="spirit-button__inner spirit-button__inner--active" for="level_one_time"><input id="level_one_time" name="level_one_time" value="true" type="radio"
class="spirit-button__input spirit-button__checkbox" checked=""> <span class="spirit-form__radio-inner"><span class="spirit-form__radio-label">One Time Gift</span></span></label></div>
</div>
<div class="spirit-col-md-6 spirit-col-md-auto form-item-radio monthly-gift-radio">
<div class="spirit-button spirit-button--toggle"><label class="spirit-button__inner" for="level_autorepeat"><input id="level_autorepeat" name="level_autorepeat" value="true" type="radio" class="spirit-button__input spirit-button__checkbox">
<span class="spirit-form__radio-inner"><span class="spirit-form__radio-label">Monthly Gift</span></span></label></div>
</div>
<div class="one-time-gift-radio-tooltip-div spirit-col-12">
<p class="spirit-body-text-m one-time-gift-radio-tooltip-text"></p>
</div>
</div>
<div class="form__error spirit-d-none"><span class="spirit-form__field-error" role="alert"><svg aria-label="alert-circle" class="spirit-icon spirit-form__field-error-icon" aria-hidden="true">
<use xlink:href="#alert-circle"></use>
</svg> <span class="spirit-form__field-error-text ask-string-error-container js--ask-string-error-container"></span></span></div>
<div class="js--form-ask-string spirit-form__field-group" id="ask-string">
<div class="spirit-row js--ask-ladder donation-list">
<div class="spirit-col-4">
<div class="spirit-button spirit-button--toggle"><input class="spirit-button__input spirit-button__checkbox" type="radio" name="level_id" id="level_id-102942" value="102942" required=""
data-parsley-errors-container=".ask-string-error-container" data-parsley-error-message="Please select a donation amount."><label for="level_id-102942" class="btn spirit-button__inner" tabindex="0">$500</label></div>
</div>
<div class="spirit-col-4">
<div class="spirit-button spirit-button--toggle"><input class="spirit-button__input spirit-button__checkbox" type="radio" name="level_id" id="level_id-102943" value="102943"><label for="level_id-102943" class="btn spirit-button__inner"
tabindex="0">$250</label></div>
</div>
<div class="spirit-col-4">
<div class="spirit-button spirit-button--toggle"><input class="spirit-button__input spirit-button__checkbox" type="radio" name="level_id" id="level_id-102939" value="102939"><label for="level_id-102939" class="btn spirit-button__inner"
tabindex="0">$120</label></div>
</div>
<div class="spirit-col-4">
<div class="spirit-button spirit-button--toggle"><input class="spirit-button__input spirit-button__checkbox" type="radio" name="level_id" id="level_id-102934" value="102934"><label for="level_id-102934" class="btn spirit-button__inner"
tabindex="0">$60</label></div>
</div>
<div class="spirit-col-4">
<div class="spirit-button spirit-button--toggle"><input class="spirit-button__input spirit-button__checkbox" type="radio" name="level_id" id="level_id-102941" value="102941"><label for="level_id-102941" class="btn spirit-button__inner"
tabindex="0">$30</label></div>
</div>
<div class="spirit-col-4">
<div class="spirit-button spirit-button--toggle"><input class="spirit-button__input spirit-button__checkbox" type="radio" name="level_id" id="level_id-102940" value="102940"><label for="level_id-102940" class="btn spirit-button__inner"
tabindex="0">$15</label></div>
</div>
</div>
<div class="spirit-row js--ask-ladder monthly-donation-list spirit-d-none">
<div class="spirit-col-4">
<div class="spirit-button spirit-button--toggle"><input class="spirit-button__input spirit-button__checkbox" type="radio" name="level_id" id="level_id-102932" value="102932"><label for="level_id-102932" class="btn spirit-button__inner"
tabindex="0">$100</label></div>
</div>
<div class="spirit-col-4">
<div class="spirit-button spirit-button--toggle"><input class="spirit-button__input spirit-button__checkbox" type="radio" name="level_id" id="level_id-102931" value="102931"><label for="level_id-102931" class="btn spirit-button__inner"
tabindex="0">$50</label></div>
</div>
<div class="spirit-col-4">
<div class="spirit-button spirit-button--toggle"><input class="spirit-button__input spirit-button__checkbox" type="radio" name="level_id" id="level_id-102935" value="102935"><label for="level_id-102935" class="btn spirit-button__inner"
tabindex="0">$30</label></div>
</div>
<div class="spirit-col-4">
<div class="spirit-button spirit-button--toggle"><input class="spirit-button__input spirit-button__checkbox" type="radio" name="level_id" id="level_id-102933" value="102933"><label for="level_id-102933" class="btn spirit-button__inner"
tabindex="0">$25</label></div>
</div>
<div class="spirit-col-4">
<div class="spirit-button spirit-button--toggle"><input class="spirit-button__input spirit-button__checkbox" type="radio" name="level_id" id="level_id-102938" value="102938"><label for="level_id-102938" class="btn spirit-button__inner"
tabindex="0">$20</label></div>
</div>
<div class="spirit-col-4">
<div class="spirit-button spirit-button--toggle"><input class="spirit-button__input spirit-button__checkbox" type="radio" name="level_id" id="level_id-102936" value="102936"><label for="level_id-102936" class="btn spirit-button__inner"
tabindex="0">$10</label></div>
</div>
</div>
<div class="spirit-row donation-other">
<div class="spirit-col-4 js--form-ask-string-other">
<div class="spirit-form__input input--other-amount"><input type="radio" class="js--amount-other-radio" name="level_id" value="102937" id="amount-other" checked="" required=""><span>$</span><input
class="spirit-form__input-field js--amount-other-input" type="text" name="other_amount" pattern="^\$?(([1-9]\d{0,2}(,\d{3})*)|(([1-9]\d*)?\d))(\.\d\d)?$" placeholder="Other" data-min-amount="$5.00" data-parsley-min="5"
data-parsley-errors-container=".ask-string-error-container" data-parsley-error-message="Please select a donation amount above $5." required=""></div>
</div>
</div>
</div>
<div class="spirit-row spirit-justify-content-center form-separator">
<div class="spirit-col-auto"><img src="../jdrf-framework/dist/global/images/jdrf-wave-separator.png"></div>
</div>
<section class="form__section">
<h4 class="spirit-h4">Contributor</h4>
<div class="spirit-row">
<div class="spirit-col-md-6">
<div class="spirit-form__field-group"><label class="spirit-form__label" for="billing_first_name">First Name <abbr class="spirit-form__label-required-indicator" title="This field is required." aria-hidden="true">*</abbr> <span
class="spirit-form__label-accessible-text">Required Field.</span></label>
<div class="spirit-form__input"><input class="js--fill-from-text spirit-form__input-field" name="billing.name.first" type="text" id="billing_first_name" value="" required="" data-parsley-error-message="First name is required."
data-parsley-errors-container=".field-error-text--first-name">
<div class="spirit-form__input-icon-wrap"><svg aria-label="alert-circle" class="spirit-icon spirit-form__input-icon" aria-hidden="true">
<use xlink:href="#alert-circle"></use>
</svg></div>
</div><span class="spirit-form__field-error" role="alert"><span class="spirit-form__field-error-text field-error-text--first-name"></span></span>
</div>
</div>
<div class="spirit-col-md-6">
<div class="spirit-form__field-group"><label class="spirit-form__label" for="billing_last_name">Last Name <abbr class="spirit-form__label-required-indicator" title="This field is required." aria-hidden="true">*</abbr> <span
class="spirit-form__label-accessible-text">Required Field.</span></label>
<div class="spirit-form__input"><input class="spirit-form__input-field js--fill-from-text" name="billing.name.last" type="text" id="billing_last_name" value="" required="" data-parsley-error-message="Last name is required."
data-parsley-errors-container=".field-error-text--last-name">
<div class="spirit-form__input-icon-wrap"><svg aria-label="alert-circle" class="spirit-icon spirit-form__input-icon" aria-hidden="true">
<use xlink:href="#alert-circle"></use>
</svg></div>
</div><span class="spirit-form__field-error" role="alert"><span class="spirit-form__field-error-text field-error-text--last-name"></span></span>
</div>
</div>
</div>
<div class="spirit-form__field-group"><label class="spirit-form__label" for="donor_email">Email <abbr class="spirit-form__label-required-indicator" title="This field is required." aria-hidden="true">*</abbr> <span
class="spirit-form__label-accessible-text">Required Field.</span></label>
<div class="spirit-form__input"><input class="spirit-form__input-field js--fill-from-text" name="donor.email" id="donor_email" type="email" value="" required="" data-parsley-error-message="Please enter a valid email address."
data-parsley-errors-container=".field-error-text--email">
<div class="spirit-form__input-icon-wrap"><svg aria-label="alert-circle" class="spirit-icon spirit-form__input-icon" aria-hidden="true">
<use xlink:href="#alert-circle"></use>
</svg></div>
</div><span class="spirit-form__field-error" role="alert"><span class="spirit-form__field-error-text field-error-text--email"></span></span>
</div>
<div class="spirit-row">
<div class="spirit-col-md-8">
<div class="spirit-form__field-group"><label class="spirit-form__label" for="billing_address_street1">Street Address <abbr class="spirit-form__label-required-indicator" title="This field is required." aria-hidden="true">*</abbr> <span
class="spirit-form__label-accessible-text">Required Field.</span></label>
<div class="spirit-form__input"><input class="spirit-form__input-field" name="billing.address.street1" id="billing_address_street1" type="text" value="" required="" data-parsley-error-message="Address is required."
data-parsley-errors-container=".field-error-text--address">
<div class="spirit-form__input-icon-wrap"><svg aria-label="alert-circle" class="spirit-icon spirit-form__input-icon" aria-hidden="true">
<use xlink:href="#alert-circle"></use>
</svg></div>
</div><span class="spirit-form__field-error" role="alert"><span class="spirit-form__field-error-text field-error-text--address"></span></span>
</div>
</div>
<div class="spirit-col-md-4">
<div class="spirit-form__field-group"><label class="spirit-form__label" for="billing_address_street2">Line 2</label>
<div class="spirit-form__input"><input class="spirit-form__input-field" placeholder="Optional" name="billing.address.street2" id="billing_address_street2" type="text" value="">
<div class="spirit-form__input-icon-wrap"><svg aria-label="alert-circle" class="spirit-icon spirit-form__input-icon" aria-hidden="true">
<use xlink:href="#alert-circle"></use>
</svg></div>
</div>
</div>
</div>
</div>
<div class="spirit-row">
<div class="spirit-col-md-6">
<div class="spirit-form__field-group"><label class="spirit-form__label" for="billing_address_zip">Zip Code <abbr class="spirit-form__label-required-indicator" title="This field is required." aria-hidden="true">*</abbr> <span
class="spirit-form__label-accessible-text">Required Field.</span></label>
<div class="spirit-form__input"><input class="js--billing-address-zip spirit-form__input-field" name="billing.address.zip" type="text" id="billing_address_zip" value="" required="" data-parsley-error-message="Zipcode is required."
data-parsley-errors-container=".field-error-text--zip">
<div class="spirit-form__input-icon-wrap"><svg aria-label="alert-circle" class="spirit-icon spirit-form__input-icon" aria-hidden="true">
<use xlink:href="#alert-circle"></use>
</svg></div>
</div><span class="spirit-form__field-error" role="alert"><span class="spirit-form__field-error-text field-error-text--zip"></span></span>
</div>
</div>
<div class="spirit-col-md-6 form-row js--form-country-select">
<div class="spirit-form__field-group"><label class="spirit-form__label" for="billing_address_country">Country <abbr class="spirit-form__label-required-indicator" title="This field is required." aria-hidden="true">*</abbr> <span
class="spirit-form__label-accessible-text">Required Field.</span></label>
<div class="spirit-form__select"><select name="billing.address.country" id="billing_address_country" size="1" required="" data-parsley-error-message="Country is required." data-parsley-errors-container=".field-error-text--country"
class="spirit-form__select-input">
<option class="spirit-form__select-option"></option>
<option value="United States" class="spirit-form__select-option">United States</option>
<option value="Afghanistan" class="spirit-form__select-option">Afghanistan</option>
<option value="Aland Islands" class="spirit-form__select-option">Aland Islands</option>
<option value="Albania" class="spirit-form__select-option">Albania</option>
<option value="Algeria" class="spirit-form__select-option">Algeria</option>
<option value="American Samoa" class="spirit-form__select-option">American Samoa</option>
<option value="Andorra" class="spirit-form__select-option">Andorra</option>
<option value="Angola" class="spirit-form__select-option">Angola</option>
<option value="Anguilla" class="spirit-form__select-option">Anguilla</option>
<option value="Antarctica" class="spirit-form__select-option">Antarctica</option>
<option value="Antigua and Barbuda" class="spirit-form__select-option">Antigua and Barbuda</option>
<option value="Argentina" class="spirit-form__select-option">Argentina</option>
<option value="Armenia" class="spirit-form__select-option">Armenia</option>
<option value="Aruba" class="spirit-form__select-option">Aruba</option>
<option value="Australia" class="spirit-form__select-option">Australia</option>
<option value="Austria" class="spirit-form__select-option">Austria</option>
<option value="Azerbaijan" class="spirit-form__select-option">Azerbaijan</option>
<option value="Bahamas" class="spirit-form__select-option">Bahamas</option>
<option value="Bahrain" class="spirit-form__select-option">Bahrain</option>
<option value="Bangladesh" class="spirit-form__select-option">Bangladesh</option>
<option value="Barbados" class="spirit-form__select-option">Barbados</option>
<option value="Belarus" class="spirit-form__select-option">Belarus</option>
<option value="Belgium" class="spirit-form__select-option">Belgium</option>
<option value="Belize" class="spirit-form__select-option">Belize</option>
<option value="Benin" class="spirit-form__select-option">Benin</option>
<option value="Bermuda" class="spirit-form__select-option">Bermuda</option>
<option value="Bhutan" class="spirit-form__select-option">Bhutan</option>
<option value="Bolivarian Republic of Venezuela" class="spirit-form__select-option">Bolivarian Republic of Venezuela</option>
<option value="Bonaire, Sint Eustatios and Saba" class="spirit-form__select-option">Bonaire, Sint Eustatios and Saba</option>
<option value="Bosnia and Herzegovina" class="spirit-form__select-option">Bosnia and Herzegovina</option>
<option value="Botswana" class="spirit-form__select-option">Botswana</option>
<option value="Bouvet Island" class="spirit-form__select-option">Bouvet Island</option>
<option value="Brazil" class="spirit-form__select-option">Brazil</option>
<option value="British Indian Ocean Territory" class="spirit-form__select-option">British Indian Ocean Territory</option>
<option value="Brunei Darussalam" class="spirit-form__select-option">Brunei Darussalam</option>
<option value="Bulgaria" class="spirit-form__select-option">Bulgaria</option>
<option value="Burkina Faso" class="spirit-form__select-option">Burkina Faso</option>
<option value="Burundi" class="spirit-form__select-option">Burundi</option>
<option value="Cambodia" class="spirit-form__select-option">Cambodia</option>
<option value="Cameroon" class="spirit-form__select-option">Cameroon</option>
<option value="Canada" class="spirit-form__select-option">Canada</option>
<option value="Cape Verde" class="spirit-form__select-option">Cape Verde</option>
<option value="Cayman Islands" class="spirit-form__select-option">Cayman Islands</option>
<option value="Central African Republic" class="spirit-form__select-option">Central African Republic</option>
<option value="Chad" class="spirit-form__select-option">Chad</option>
<option value="Chile" class="spirit-form__select-option">Chile</option>
<option value="China" class="spirit-form__select-option">China</option>
<option value="Christmas Island" class="spirit-form__select-option">Christmas Island</option>
<option value="Cocos (Keeling) Islands" class="spirit-form__select-option">Cocos (Keeling) Islands</option>
<option value="Colombia" class="spirit-form__select-option">Colombia</option>
<option value="Comoros" class="spirit-form__select-option">Comoros</option>
<option value="Congo" class="spirit-form__select-option">Congo</option>
<option value="Cook Islands" class="spirit-form__select-option">Cook Islands</option>
<option value="Costa Rica" class="spirit-form__select-option">Costa Rica</option>
<option value="Cote D'Ivoire" class="spirit-form__select-option">Cote D'Ivoire</option>
<option value="Croatia" class="spirit-form__select-option">Croatia</option>
<option value="Cuba" class="spirit-form__select-option">Cuba</option>
<option value="Curacao" class="spirit-form__select-option">Curacao</option>
<option value="Cyprus" class="spirit-form__select-option">Cyprus</option>
<option value="Czech Republic" class="spirit-form__select-option">Czech Republic</option>
<option value="Democratic People's Republic of Korea" class="spirit-form__select-option">Democratic People's Republic of Korea</option>
<option value="The Democratic Republic of the Congo" class="spirit-form__select-option">The Democratic Republic of the Congo</option>
<option value="Denmark" class="spirit-form__select-option">Denmark</option>
<option value="Djibouti" class="spirit-form__select-option">Djibouti</option>
<option value="Dominica" class="spirit-form__select-option">Dominica</option>
<option value="Dominican Republic" class="spirit-form__select-option">Dominican Republic</option>
<option value="Ecuador" class="spirit-form__select-option">Ecuador</option>
<option value="Egypt" class="spirit-form__select-option">Egypt</option>
<option value="El Salvador" class="spirit-form__select-option">El Salvador</option>
<option value="Equatorial Guinea" class="spirit-form__select-option">Equatorial Guinea</option>
<option value="Eritrea" class="spirit-form__select-option">Eritrea</option>
<option value="Estonia" class="spirit-form__select-option">Estonia</option>
<option value="Ethiopia" class="spirit-form__select-option">Ethiopia</option>
<option value="Falkland Islands (Malvinas)" class="spirit-form__select-option">Falkland Islands (Malvinas)</option>
<option value="Faroe Islands" class="spirit-form__select-option">Faroe Islands</option>
<option value="Federated States of Micronesia" class="spirit-form__select-option">Federated States of Micronesia</option>
<option value="Fiji" class="spirit-form__select-option">Fiji</option>
<option value="Finland" class="spirit-form__select-option">Finland</option>
<option value="The Former Yugoslav Republic of Macedonia" class="spirit-form__select-option">The Former Yugoslav Republic of Macedonia</option>
<option value="France" class="spirit-form__select-option">France</option>
<option value="French Guiana" class="spirit-form__select-option">French Guiana</option>
<option value="French Polynesia" class="spirit-form__select-option">French Polynesia</option>
<option value="French Southern Territories" class="spirit-form__select-option">French Southern Territories</option>
<option value="Gabon" class="spirit-form__select-option">Gabon</option>
<option value="Gambia" class="spirit-form__select-option">Gambia</option>
<option value="Georgia" class="spirit-form__select-option">Georgia</option>
<option value="Germany" class="spirit-form__select-option">Germany</option>
<option value="Ghana" class="spirit-form__select-option">Ghana</option>
<option value="Gibraltar" class="spirit-form__select-option">Gibraltar</option>
<option value="Greece" class="spirit-form__select-option">Greece</option>
<option value="Greenland" class="spirit-form__select-option">Greenland</option>
<option value="Grenada" class="spirit-form__select-option">Grenada</option>
<option value="Guadeloupe" class="spirit-form__select-option">Guadeloupe</option>
<option value="Guam" class="spirit-form__select-option">Guam</option>
<option value="Guatemala" class="spirit-form__select-option">Guatemala</option>
<option value="Guernsey" class="spirit-form__select-option">Guernsey</option>
<option value="Guinea" class="spirit-form__select-option">Guinea</option>
<option value="Guinea-Bissau" class="spirit-form__select-option">Guinea-Bissau</option>
<option value="Guyana" class="spirit-form__select-option">Guyana</option>
<option value="Haiti" class="spirit-form__select-option">Haiti</option>
<option value="Heard Island and McDonald Islands" class="spirit-form__select-option">Heard Island and McDonald Islands</option>
<option value="Holy See (Vatican City State)" class="spirit-form__select-option">Holy See (Vatican City State)</option>
<option value="Honduras" class="spirit-form__select-option">Honduras</option>
<option value="Hong Kong" class="spirit-form__select-option">Hong Kong</option>
<option value="Hungary" class="spirit-form__select-option">Hungary</option>
<option value="Iceland" class="spirit-form__select-option">Iceland</option>
<option value="India" class="spirit-form__select-option">India</option>
<option value="Indonesia" class="spirit-form__select-option">Indonesia</option>
<option value="Iraq" class="spirit-form__select-option">Iraq</option>
<option value="Ireland" class="spirit-form__select-option">Ireland</option>
<option value="Islamic Republic of Iran" class="spirit-form__select-option">Islamic Republic of Iran</option>
<option value="Isle of Man" class="spirit-form__select-option">Isle of Man</option>
<option value="Israel" class="spirit-form__select-option">Israel</option>
<option value="Italy" class="spirit-form__select-option">Italy</option>
<option value="Jamaica" class="spirit-form__select-option">Jamaica</option>
<option value="Japan" class="spirit-form__select-option">Japan</option>
<option value="Jersey" class="spirit-form__select-option">Jersey</option>
<option value="Jordan" class="spirit-form__select-option">Jordan</option>
<option value="Kazakhstan" class="spirit-form__select-option">Kazakhstan</option>
<option value="Kenya" class="spirit-form__select-option">Kenya</option>
<option value="Kiribati" class="spirit-form__select-option">Kiribati</option>
<option value="Kuwait" class="spirit-form__select-option">Kuwait</option>
<option value="Kyrgyzstan" class="spirit-form__select-option">Kyrgyzstan</option>
<option value="Lao People's Democratic Republic" class="spirit-form__select-option">Lao People's Democratic Republic</option>
<option value="Latvia" class="spirit-form__select-option">Latvia</option>
<option value="Lebanon" class="spirit-form__select-option">Lebanon</option>
<option value="Lesotho" class="spirit-form__select-option">Lesotho</option>
<option value="Liberia" class="spirit-form__select-option">Liberia</option>
<option value="Libya" class="spirit-form__select-option">Libya</option>
<option value="Liechtenstein" class="spirit-form__select-option">Liechtenstein</option>
<option value="Lithuania" class="spirit-form__select-option">Lithuania</option>
<option value="Luxembourg" class="spirit-form__select-option">Luxembourg</option>
<option value="Macao" class="spirit-form__select-option">Macao</option>
<option value="Madagascar" class="spirit-form__select-option">Madagascar</option>
<option value="Malawi" class="spirit-form__select-option">Malawi</option>
<option value="Malaysia" class="spirit-form__select-option">Malaysia</option>
<option value="Maldives" class="spirit-form__select-option">Maldives</option>
<option value="Mali" class="spirit-form__select-option">Mali</option>
<option value="Malta" class="spirit-form__select-option">Malta</option>
<option value="Marshall Islands" class="spirit-form__select-option">Marshall Islands</option>
<option value="Martinique" class="spirit-form__select-option">Martinique</option>
<option value="Mauritania" class="spirit-form__select-option">Mauritania</option>
<option value="Mauritius" class="spirit-form__select-option">Mauritius</option>
<option value="Mayotte" class="spirit-form__select-option">Mayotte</option>
<option value="Mexico" class="spirit-form__select-option">Mexico</option>
<option value="Monaco" class="spirit-form__select-option">Monaco</option>
<option value="Mongolia" class="spirit-form__select-option">Mongolia</option>
<option value="Montenegro" class="spirit-form__select-option">Montenegro</option>
<option value="Montserrat" class="spirit-form__select-option">Montserrat</option>
<option value="Morocco" class="spirit-form__select-option">Morocco</option>
<option value="Mozambique" class="spirit-form__select-option">Mozambique</option>
<option value="Myanmar" class="spirit-form__select-option">Myanmar</option>
<option value="Namibia" class="spirit-form__select-option">Namibia</option>
<option value="Nauru" class="spirit-form__select-option">Nauru</option>
<option value="Nepal" class="spirit-form__select-option">Nepal</option>
<option value="Netherlands" class="spirit-form__select-option">Netherlands</option>
<option value="New Caledonia" class="spirit-form__select-option">New Caledonia</option>
<option value="New Zealand" class="spirit-form__select-option">New Zealand</option>
<option value="Nicaragua" class="spirit-form__select-option">Nicaragua</option>
<option value="Niger" class="spirit-form__select-option">Niger</option>
<option value="Nigeria" class="spirit-form__select-option">Nigeria</option>
<option value="Niue" class="spirit-form__select-option">Niue</option>
<option value="Norfolk Island" class="spirit-form__select-option">Norfolk Island</option>
<option value="Northern Mariana Islands" class="spirit-form__select-option">Northern Mariana Islands</option>
<option value="Norway" class="spirit-form__select-option">Norway</option>
<option value="Oman" class="spirit-form__select-option">Oman</option>
<option value="Pakistan" class="spirit-form__select-option">Pakistan</option>
<option value="Palau" class="spirit-form__select-option">Palau</option>
<option value="Palestinian Territory, Occupied" class="spirit-form__select-option">Palestinian Territory, Occupied</option>
<option value="Panama" class="spirit-form__select-option">Panama</option>
<option value="Papua New Guinea" class="spirit-form__select-option">Papua New Guinea</option>
<option value="Paraguay" class="spirit-form__select-option">Paraguay</option>
<option value="Peru" class="spirit-form__select-option">Peru</option>
<option value="Philippines" class="spirit-form__select-option">Philippines</option>
<option value="Pitcairn" class="spirit-form__select-option">Pitcairn</option>
<option value="Plurinational State of Bolivia" class="spirit-form__select-option">Plurinational State of Bolivia</option>
<option value="Poland" class="spirit-form__select-option">Poland</option>
<option value="Portugal" class="spirit-form__select-option">Portugal</option>
<option value="Puerto Rico" class="spirit-form__select-option">Puerto Rico</option>
<option value="Qatar" class="spirit-form__select-option">Qatar</option>
<option value="Republic of Korea" class="spirit-form__select-option">Republic of Korea</option>
<option value="Republic of Moldova" class="spirit-form__select-option">Republic of Moldova</option>
<option value="Reunion" class="spirit-form__select-option">Reunion</option>
<option value="Romania" class="spirit-form__select-option">Romania</option>
<option value="Russian Federation" class="spirit-form__select-option">Russian Federation</option>
<option value="Rwanda" class="spirit-form__select-option">Rwanda</option>
<option value="Saint Barthelemy" class="spirit-form__select-option">Saint Barthelemy</option>
<option value="Saint Helena, Ascension and Tristan da Cunha" class="spirit-form__select-option">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="Saint Kitts and Nevis" class="spirit-form__select-option">Saint Kitts and Nevis</option>
<option value="Saint Lucia" class="spirit-form__select-option">Saint Lucia</option>
<option value="Saint Martin (French)" class="spirit-form__select-option">Saint Martin (French)</option>
<option value="Saint Pierre and Miquelon" class="spirit-form__select-option">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines" class="spirit-form__select-option">Saint Vincent and the Grenadines</option>
<option value="Samoa" class="spirit-form__select-option">Samoa</option>
<option value="San Marino" class="spirit-form__select-option">San Marino</option>
<option value="Sao Tome and Principe" class="spirit-form__select-option">Sao Tome and Principe</option>
<option value="Saudi Arabia" class="spirit-form__select-option">Saudi Arabia</option>
<option value="Senegal" class="spirit-form__select-option">Senegal</option>
<option value="Serbia" class="spirit-form__select-option">Serbia</option>
<option value="Seychelles" class="spirit-form__select-option">Seychelles</option>
<option value="S. Georgia & S. Sandwich Isls." class="spirit-form__select-option">S. Georgia & S. Sandwich Isls.</option>
<option value="Sierra Leone" class="spirit-form__select-option">Sierra Leone</option>
<option value="Singapore" class="spirit-form__select-option">Singapore</option>
<option value="Sint Maarten (Dutch)" class="spirit-form__select-option">Sint Maarten (Dutch)</option>
<option value="Slovakia" class="spirit-form__select-option">Slovakia</option>
<option value="Slovenia" class="spirit-form__select-option">Slovenia</option>
<option value="Solomon Islands" class="spirit-form__select-option">Solomon Islands</option>
<option value="Somalia" class="spirit-form__select-option">Somalia</option>
<option value="South Africa" class="spirit-form__select-option">South Africa</option>
<option value="South Sudan" class="spirit-form__select-option">South Sudan</option>
<option value="Spain" class="spirit-form__select-option">Spain</option>
<option value="Sri Lanka" class="spirit-form__select-option">Sri Lanka</option>
<option value="Sudan" class="spirit-form__select-option">Sudan</option>
<option value="Suriname" class="spirit-form__select-option">Suriname</option>
<option value="Svalbard and Jan Mayen" class="spirit-form__select-option">Svalbard and Jan Mayen</option>
<option value="Swaziland" class="spirit-form__select-option">Swaziland</option>
<option value="Sweden" class="spirit-form__select-option">Sweden</option>
<option value="Switzerland" class="spirit-form__select-option">Switzerland</option>
<option value="Syrian Arab Republic" class="spirit-form__select-option">Syrian Arab Republic</option>
<option value="Taiwan, Province of China" class="spirit-form__select-option">Taiwan, Province of China</option>
<option value="Tajikistan" class="spirit-form__select-option">Tajikistan</option>
<option value="Thailand" class="spirit-form__select-option">Thailand</option>
<option value="Timor-Leste" class="spirit-form__select-option">Timor-Leste</option>
<option value="Togo" class="spirit-form__select-option">Togo</option>
<option value="Tokelau" class="spirit-form__select-option">Tokelau</option>
<option value="Tonga" class="spirit-form__select-option">Tonga</option>
<option value="Trinidad and Tobago" class="spirit-form__select-option">Trinidad and Tobago</option>
<option value="Tunisia" class="spirit-form__select-option">Tunisia</option>
<option value="Turkey" class="spirit-form__select-option">Turkey</option>
<option value="Turkmenistan" class="spirit-form__select-option">Turkmenistan</option>
<option value="Turks and Caicos Islands" class="spirit-form__select-option">Turks and Caicos Islands</option>
<option value="Tuvalu" class="spirit-form__select-option">Tuvalu</option>
<option value="Uganda" class="spirit-form__select-option">Uganda</option>
<option value="Ukraine" class="spirit-form__select-option">Ukraine</option>
<option value="United Arab Emirates" class="spirit-form__select-option">United Arab Emirates</option>
<option value="United Kingdom" class="spirit-form__select-option">United Kingdom</option>
<option value="United Republic of Tanzania" class="spirit-form__select-option">United Republic of Tanzania</option>
<option value="Uruguay" class="spirit-form__select-option">Uruguay</option>
<option value="USA Minor Outlying Islands" class="spirit-form__select-option">USA Minor Outlying Islands</option>
<option value="Uzbekistan" class="spirit-form__select-option">Uzbekistan</option>
<option value="Vanuatu" class="spirit-form__select-option">Vanuatu</option>
<option value="Viet Nam" class="spirit-form__select-option">Viet Nam</option>
<option value="Virgin Islands (British)" class="spirit-form__select-option">Virgin Islands (British)</option>
<option value="Virgin Islands (USA)" class="spirit-form__select-option">Virgin Islands (USA)</option>
<option value="Wallis and Futuna" class="spirit-form__select-option">Wallis and Futuna</option>
<option value="Western Sahara" class="spirit-form__select-option">Western Sahara</option>
<option value="Yemen" class="spirit-form__select-option">Yemen</option>
<option value="Zambia" class="spirit-form__select-option">Zambia</option>
<option value="Zimbabwe" class="spirit-form__select-option">Zimbabwe</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('billing.address.country', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing.address.country_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<div class="spirit-form__select-inner"></div><span class="spirit-form__select-open-indicator"><svg aria-label="chevron-down" class="spirit-icon spirit-form__select-open-icon" aria-hidden="true">
<use xlink:href="#chevron-down"></use>
</svg></span>
</div><span class="spirit-form__field-error" role="alert"><span class="spirit-form__field-error-text field-error-text--country"></span></span>
</div>
</div>
</div>
<div class="spirit-row">
<div class="spirit-col-md-6 form-row">
<div class="spirit-form__field-group"><label class="spirit-form__label" for="billing_address_city">City <abbr class="spirit-form__label-required-indicator" title="This field is required." aria-hidden="true">*</abbr> <span
class="spirit-form__label-accessible-text">Required Field.</span></label>
<div class="spirit-form__input"><input class="js--billing-address-city spirit-form__input-field" name="billing.address.city" type="text" id="billing_address_city" value="" required="" data-parsley-error-message="City is required."
data-parsley-errors-container=".field-error-text--city">
<div class="spirit-form__input-icon-wrap"><svg aria-label="alert-circle" class="spirit-icon spirit-form__input-icon" aria-hidden="true">
<use xlink:href="#alert-circle"></use>
</svg></div>
</div><span class="spirit-form__field-error" role="alert"><span class="spirit-form__field-error-text field-error-text--city"></span></span>
</div>
</div>
<div class="spirit-col-md-6 form-row js--form-state-select">
<div class="spirit-form__field-group"><label class="spirit-form__label" for="billing_address_state">State <abbr class="spirit-form__label-required-indicator" title="This field is required." aria-hidden="true">*</abbr> <span
class="spirit-form__label-accessible-text">Required Field.</span></label>
<div class="spirit-form__select"><select name="billing.address.state" id="billing_address_state" size="1" required="" data-parsley-error-message="State is required." data-parsley-errors-container=".field-error-text--state"
class="spirit-form__select-input">
<option></option>
<option value="AK">AK - Alaska</option>
<option value="AL">AL - Alabama</option>
<option value="AR">AR - Arkansas</option>
<option value="AZ">AZ - Arizona</option>
<option value="CA">CA - California</option>
<option value="CO">CO - Colorado</option>
<option value="CT">CT - Connecticut</option>
<option value="DC">DC - District of Columbia</option>
<option value="DE">DE - Delaware</option>
<option value="FL">FL - Florida</option>
<option value="GA">GA - Georgia</option>
<option value="HI">HI - Hawaii</option>
<option value="IA">IA - Iowa</option>
<option value="ID">ID - Idaho</option>
<option value="IL">IL - Illinois</option>
<option value="IN">IN - Indiana</option>
<option value="KS">KS - Kansas</option>
<option value="KY">KY - Kentucky</option>
<option value="LA">LA - Louisiana</option>
<option value="MA">MA - Massachusetts</option>
<option value="MD">MD - Maryland</option>
<option value="ME">ME - Maine</option>
<option value="MI">MI - Michigan</option>
<option value="MN">MN - Minnesota</option>
<option value="MO">MO - Missouri</option>
<option value="MS">MS - Mississippi</option>
<option value="MT">MT - Montana</option>
<option value="NC">NC - North Carolina</option>
<option value="ND">ND - North Dakota</option>
<option value="NE">NE - Nebraska</option>
<option value="NH">NH - New Hampshire</option>
<option value="NJ">NJ - New Jersey</option>
<option value="NM">NM - New Mexico</option>
<option value="NV">NV - Nevada</option>
<option value="NY">NY - New York</option>
<option value="OH">OH - Ohio</option>
<option value="OK">OK - Oklahoma</option>
<option value="OR">OR - Oregon</option>
<option value="PA">PA - Pennsylvania</option>
<option value="RI">RI - Rhode Island</option>
<option value="SC">SC - South Carolina</option>
<option value="SD">SD - South Dakota</option>
<option value="TN">TN - Tennessee</option>
<option value="TX">TX - Texas</option>
<option value="UT">UT - Utah</option>
<option value="VA">VA - Virginia</option>
<option value="VT">VT - Vermont</option>
<option value="WA">WA - Washington</option>
<option value="WI">WI - Wisconsin</option>
<option value="WV">WV - West Virginia</option>
<option value="WY">WY - Wyoming</option>
<option value="AS">AS - American Samoa</option>
<option value="FM">FM - Federated States of Micronesia</option>
<option value="GU">GU - Guam</option>
<option value="MH">MH - Marshall Islands</option>
<option value="MP">MP - Northern Mariana Islands</option>
<option value="PR">PR - Puerto Rico</option>
<option value="PW">PW - Palau</option>
<option value="VI">VI - Virgin Islands</option>
<option value="AA">AA - Armed Forces Americas</option>
<option value="AE">AE - Armed Forces</option>
<option value="AP">AP - Armed Forces Pacific</option>
<option value="AB">AB - Alberta</option>
<option value="BC">BC - British Columbia</option>
<option value="MB">MB - Manitoba</option>
<option value="NB">NB - New Brunswick</option>
<option value="NL">NL - Newfoundland and Labrador</option>
<option value="NS">NS - Nova Scotia</option>
<option value="NT">NT - Northwest Territories</option>
<option value="NU">NU - Nunavut</option>
<option value="ON">ON - Ontario</option>
<option value="PE">PE - Prince Edward Island</option>
<option value="QC">QC - Quebec</option>
<option value="SK">SK - Saskatchewan</option>
<option value="YT">YT - Yukon</option>
<option value="None">None</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('billing.address.state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing.address.state_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<div class="spirit-form__select-inner"></div><span class="spirit-form__select-open-indicator"><svg aria-label="chevron-down" class="spirit-icon spirit-form__select-open-icon" aria-hidden="true">
<use xlink:href="#chevron-down"></use>
</svg></span>
</div><span class="spirit-form__field-error" role="alert"><span class="spirit-form__field-error-text field-error-text--state"></span></span>
</div>
</div>
</div>
<div class="spirit-form__field-group"><label class="spirit-form__label" for="donor_phone">Phone Number <span class="spirit-form__label-optional">(Optional)</span></label>
<div class="spirit-form__input"><input class="spirit-form__input-field" name="donor.phone" id="donor_phone" type="text" value=""></div>
</div><label class="spirit-form__checkbox" for="donor_email_opt_in"><input type="checkbox" name="donor.email_opt_in" id="donor_email_opt_in" class="spirit-form__checkbox-input js--donor-email-opt-in checkmark-input" value="true" checked="">
<span class="spirit-form__checkbox-inner"><span class="spirit-form__checkbox-visual"><svg aria-label="check" class="spirit-icon spirit-form__checkbox-checked-icon" aria-hidden="true">
<use xlink:href="#check"></use>
</svg> </span><span class="spirit-form__checkbox-label">Opt In to General News from JDRF</span></span></label>
</section>
<div class="spirit-row spirit-justify-content-center form-separator">
<div class="spirit-col-auto"><img src="../jdrf-framework/dist/global/images/jdrf-wave-separator.png"></div>
</div>
<section class="form-section form-section--payment">
<div class="spirit-row">
<div class="spirit-col-12">
<h4 class="spirit-h4">Payment Information</h4>
</div>
</div>
<div class="spirit-form__field-group"><label class="spirit-form__label" for="payment_typepay_typelist">Payment Type <abbr class="spirit-form__label-required-indicator" title="This field is required." aria-hidden="true">*</abbr> <span
class="spirit-form__label-accessible-text">Required Field.</span></label>
<div class="spirit-form__select"><select class="spirit-form__select-input js--payment-type-list" id="payment_typepay_typelist" size="1" required="">
<option class="spirit-form__select-option" value="credit" selected="">Credit Card</option>
<option value="ach">Bank Account Withdrawal</option>
<option value="paypal">PayPal</option>
</select>
<div class="spirit-form__select-inner"></div><span class="spirit-form__select-open-indicator"><svg aria-label="chevron-down" class="spirit-icon spirit-form__select-open-icon" aria-hidden="true">
<use xlink:href="#chevron-down"></use>
</svg> </span><input type="hidden" name="extproc" class="js--external-processor" value="">
</div>
</div>
<div class="form-item form-item--payment-option js--form-row-payment-option js--form-row-payment-option--credit">
<div class="spirit-form__field-group"><label class="spirit-form__label" for="card_number">Card Number <abbr class="spirit-form__label-required-indicator" title="This field is required." aria-hidden="true">*</abbr> <span
class="spirit-form__label-accessible-text">Required Field.</span></label>
<div class="spirit-form__input"><input class="spirit-form__input-field" name="card_number" id="card_number" type="text" data-parsley-type="number" data-parsley-length="[13,19]"
data-parsley-error-message="Please enter a valid credit card number." data-parsley-errors-container=".field-error-text--card-num" required="">
<div class="spirit-form__input-icon-wrap"><svg aria-label="alert-circle" class="spirit-icon spirit-form__input-icon" aria-hidden="true">
<use xlink:href="#alert-circle"></use>
</svg></div>
</div><span class="spirit-form__field-error" role="alert"><span class="spirit-form__field-error-text field-error-text--card-num"></span></span>
</div>
<div class="spirit-row spirit-row--selects">
<div class="spirit-col-4">
<div class="spirit-form__field-group"><label class="spirit-form__label" for="card_exp_date_month">Exp. Month <abbr class="spirit-form__label-required-indicator" title="This field is required." aria-hidden="true">*</abbr> <span
class="spirit-form__label-accessible-text">Required Field.</span></label>
<div class="spirit-form__select"><select class="spirit-form__select-input" name="card_exp_date_month" id="card_exp_date_month" data-parsley-error-message="Month is required."
data-parsley-errors-container=".field-error-text--card-exp-month" required="">
<option class="spirit-form__select-option" value="" selected="">Month</option>
<option class="spirit-form__select-option" value="01">01</option>
<option class="spirit-form__select-option" value="02">02</option>
<option class="spirit-form__select-option" value="03">03</option>
<option class="spirit-form__select-option" value="04">04</option>
<option class="spirit-form__select-option" value="05">05</option>
<option class="spirit-form__select-option" value="06">06</option>
<option class="spirit-form__select-option" value="07">07</option>
<option class="spirit-form__select-option" value="08">08</option>
<option class="spirit-form__select-option" value="09">09</option>
<option class="spirit-form__select-option" value="10">10</option>
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<div class="spirit-form__select"><select class="spirit-form__select-input" name="card_exp_date_year" id="card_exp_date_year" data-parsley-error-message="Year is required." data-parsley-errors-container=".field-error-text--card-exp-year"
required="">
<option class="spirit-form__select-option" value="" selected="">Year</option>
<option value="2023">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>
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<div class="spirit-form__input"><input class="spirit-form__input-field" name="card_cvv" id="card_cvv" type="text" data-parsley-type="number" data-parsley-length="[3,4]" data-parsley-error-message="Please enter a valid security code."
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class="spirit-form__label-accessible-text">Required Field.</span> <span
class="spirit-form__label-annotation"><a href="https://secure2.convio.net/help/site/SPageServer?s_site=jdrf3&pagename=User_Donation_ACH" target="_blank" style="text-decoration:none;position:relative;top:-2px" tabindex="100"><svg aria-label="help-circle" class="spirit-icon helper-icon" aria-hidden="true"><use xlink:href="#help-circle"></use></svg></a></span></label>
<div class="spirit-form__input"><input class="spirit-form__input-field" name="ach_routing" id="ach_routing" type="text" data-parsley-type="number" data-parsley-length="[9,9]" data-parsley-error-message="Routing number is required."
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class="spirit-form__label-accessible-text">Required Field.</span></label>
<div class="spirit-form__select"><select class="spirit-form__select-input" name="ach_account_type" id="ach_account_type" data-parsley-error-message="Account type is required." data-parsley-errors-container=".field-error-text--ach-type">
<option class="spirit-form__select-option" value="" selected=""></option>
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<option class="spirit-form__select-option" value="SAVINGS">Savings</option>
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<div class="spirit-form__field-group"><label class="spirit-form__label" for="ach_account">Account number <abbr class="spirit-form__label-required-indicator" title="This field is required." aria-hidden="true">*</abbr> <span
class="spirit-form__label-accessible-text">Required Field.</span></label>
<div class="spirit-form__input"><input class="spirit-form__input-field" name="ach_account" id="ach_account" type="text" data-parsley-error-message="Account number is required." data-parsley-errors-container=".field-error-text--ach-num">
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<div class="spirit-form__field-group"><label class="spirit-form__label" for="ach_account">Verify Account number <abbr class="spirit-form__label-required-indicator" title="This field is required." aria-hidden="true">*</abbr> <span
class="spirit-form__label-accessible-text">Required Field.</span></label>
<div class="spirit-form__input"><input class="spirit-form__input-field" id="ach_account_verify" type="text" data-parsley-equalto="#ach_account" data-parsley-error-message="Account number is required."
data-parsley-errors-container=".field-error-text--ach-num-verify">
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</svg> </span><span class="spirit-form__checkbox-label">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.
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</form>Text Content
SUPPORT LIFE-CHANGING T1D BREAKTHROUGHS Your gift today will help us continue our work toward the next breakthrough, toward a better life for everyone living with T1D, and toward a world without this disease. Thank you! FREQUENCY One Time Gift Monthly Gift $500 $250 $120 $60 $30 $15 $100 $50 $30 $25 $20 $10 $ CONTRIBUTOR First Name * Required Field. Last Name * Required Field. Email * Required Field. Street Address * Required Field. Line 2 Zip Code * Required Field. Country * Required Field. 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 Required City * Required Field. State * Required Field. AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida GA - Georgia HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming AS - American Samoa FM - Federated States of Micronesia GU - Guam MH - Marshall Islands MP - Northern Mariana Islands PR - Puerto Rico PW - Palau VI - Virgin Islands AA - Armed Forces Americas AE - Armed Forces AP - Armed Forces Pacific AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NL - Newfoundland and Labrador NS - Nova Scotia NT - Northwest Territories NU - Nunavut ON - Ontario PE - Prince Edward Island QC - Quebec SK - Saskatchewan YT - Yukon None Required Phone Number (Optional) Opt In to General News from JDRF PAYMENT INFORMATION Payment Type * Required Field. Credit CardBank Account WithdrawalPayPal Card Number * Required Field. Exp. Month * Required Field. Month010203040506070809101112 Exp. Year * Required Field. Year2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 CVV * Required Field. You will be taken to PayPal when you submit this form. Routing number * Required Field. Account type * Required Field. CheckingSavings Account number * Required Field. Verify Account number * Required Field. 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. If you would like an alternate way to give please call (800) 533-CURE (2873). Please email comments to info@jdrf.org. JDRF 200 Vesey Street, 28th Floor New York, NY 10281 JDRF 200 Vesey Street, 28th Floor New York, NY 10281 JDRF is an accredited 501(c)(3) nonprofit agency; all donations are tax deductible. A receipt will be provided via e-mail.