secure.phoenixchildrensfoundation.org
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Submitted URL: http://www.unidosporpch.org/
Effective URL: https://secure.phoenixchildrensfoundation.org/site/Donation2?df_id=11019&mfc_pref=T&11019.donation=form1&utm_source=direct&utm_medium=%28none%...
Submission: On October 21 via api from ES — Scanned from ES
Effective URL: https://secure.phoenixchildrensfoundation.org/site/Donation2?df_id=11019&mfc_pref=T&11019.donation=form1&utm_source=direct&utm_medium=%28none%...
Submission: On October 21 via api from ES — Scanned from ES
Form analysis 1 forms found in the DOM
Name: process — POST https://secure.phoenixchildrensfoundation.org/site/Donation2
<form name="process" id="ProcessForm" action="https://secure.phoenixchildrensfoundation.org/site/Donation2" method="post" onsubmit="return checkDoubleClick();">
<div class="donation-form-container responsive">
<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.app30065a?NONCE_TOKEN=E1C44B1D9E6852E83037C691410855E7', true);
xmlHttp.send();
}
addOnLoadHandler(testAjax);
//
-->
</script>
<div class="donation-form-content">
<input type="hidden" name="user_donation_amt" id="user_donation_amt" value="">
<input type="hidden" name="company_min_matching_amt" id="company_min_matching_amt" value="">
<input type="hidden" name="currency_locale" id="currency_locale" value="en_US">
<div class="form-row">
<div class="html-caption-container">
<style type="text/css">
<!--
body {
background-image: url(https://secure3.convio.net/pch/images/content/pagebuilder/2020_test_form_background.jpg);
}
.giftAmountLabel {
color: #e41e2e;
text-align: left;
font-family: 'Lexend', arial, sans-serif;
padding: 0;
font-size: 30px;
line-height: 45px;
border: none;
}
-->
</style>
<div class="hero"><img src="../images/content/pagebuilder/nash_2.png" border="0" alt="Nash" width="" height=""></div>
<span class="giftAmountLabel">Elige el monto de tu donación</span>
<div class="gift-types"><label class="freqButton selected" onclick="selectFreq(this,'single');">
<div>DONACIÓN ÚNICA</div>
</label> <label class="freqButton" onclick="selectFreq(this,'monthly');">
<div>DONACIÓN MENSUAL</div>
</label></div>
</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 field-required">
<span class="field-required"></span> <span class="aural-only">Field Is Required</span>
<span class="FormLabelText">Choose Your Gift Amount</span>
<div class="donation-level-general-ask">
</div>
<div class="donation-levels">
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded39996" value="39996" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
</div>
<label for="level_standardexpanded39996" onclick="">
<div class="donation-level-label-container"> $50 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_39996expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input active">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded39997" value="39997" checked="checked" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
</div>
<label for="level_standardexpanded39997" onclick="">
<div class="donation-level-label-container"> $100 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_39997expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded39998" value="39998" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
</div>
<label for="level_standardexpanded39998" onclick="">
<div class="donation-level-label-container"> $250 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_39998expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded39999" value="39999" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
</div>
<label for="level_standardexpanded39999" onclick="">
<div class="donation-level-label-container"> $500 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_39999expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded40000" value="40000" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
</div>
<label for="level_standardexpanded40000" onclick="">
<div class="donation-level-label-container"> $1000 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_40000expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded40001" value="40001" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
</div>
<label for="level_standardexpanded40001" onclick="">
<div class="donation-level-label-container"> $5 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_40001expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded40002" value="40002" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
</div>
<label for="level_standardexpanded40002" onclick="">
<div class="donation-level-label-container"> $10 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_40002expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded40003" value="40003" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
</div>
<label for="level_standardexpanded40003" onclick="">
<div class="donation-level-label-container"> $25 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_40003expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded40004" value="40004" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
</div>
<label for="level_standardexpanded40004" onclick="">
<div class="donation-level-label-container"> $50 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_40004expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded40005" value="40005" onclick="evalMatchingGift('');
updateDonorCoverAmount('');">
</div>
<label for="level_standardexpanded40005" onclick="">
<div class="donation-level-label-container"> $100 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_40005expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded40006" value="40006" onclick="evalMatchingGift(document.getElementById('level_standardexpanded40006amount').value);
updateDonorCoverAmount(document.getElementById('level_standardexpanded40006amount').value);">
</div>
<label for="level_standardexpanded40006" onclick="">
<div class="donation-level-label-container"> Other </div>
</label>
<div class="donation-level-user-entered">
<label for="level_standardexpanded40006amount"><span class="aural-only">Enter amount</span></label>
<input type="text" name="level_standardexpanded40006amount" id="level_standardexpanded40006amount" value="" size="12" maxlength="10"
onfocus="var el = document.getElementById ('level_standardexpanded40006');if (el) el.click(); fire_obs_comp_event('level_standardexpanded40006amount', this, event);evalMatchingGift(value); "
onchange="fire_obs_comp_event('level_standardexpanded40006amount', this, event);evalMatchingGift(value);" onkeyup="fire_obs_comp_event('level_standardexpanded40006amount', this, event);evalMatchingGift(value);"
onblur="fire_obs_comp_event('level_standardexpanded40006amount', this);updateDonorCoverAmount(value);" placeholder="Other">
</div>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_40006expandedsubmit" 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">
<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://secure.phoenixchildrensfoundation.org/site/Donation2?idb=2134726632&level_standardajaxfetch=true&df_id=11019&mfc_pref=T&11019.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="form-row">
<div class="html-caption-container">
<div class="df-copy">
<h1 class="section-header-container">Da un paso adelante. Detén el cáncer.</h1>
<p>Únete a la lucha contra el cáncer infantil. El Centro para el Cáncer y Trastornos Sanguíneos de Phoenix Children's trata a miles de jóvenes pacientes con cáncer cada año. Nuestra misión es asegurar que reciban la mejor atención desde
el momento del diagnóstico hasta la finalización del tratamiento y más allá.<br><br> Tu donación hoy nos ayuda a brindar atención de calidad mundial a los pacientes, ofrecer terapias de vanguardia y realizar investigaciones que conducen
a avances que salvan vidas.</p>
</div>
</div>
</div>
<h2 class="section-header-container"> Información del Donante </h2>
<div id="billing_first_name_row" class="form-row form-text">
<div class="form-content field-required">
<span class="field-required"></span>
<label for="billing_first_namename">Primer Nombre:</label>
<input type="text" name="billing_first_namename" id="billing_first_namename" value="" maxlength="50" placeholder="First Name">
<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 field-required">
<span class="field-required"></span>
<label for="billing_last_namename">Apellido:</label>
<input type="text" name="billing_last_namename" id="billing_last_namename" value="" maxlength="50" placeholder="Last Name">
<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="donor_email_address_row" class="form-row form-text">
<div class="form-content field-required">
<span class="field-required"></span>
<label for="donor_email_addressname"> Dirección de correo electrónico</label>
<input type="text" name="donor_email_addressname" id="donor_email_addressname" value="" maxlength="255" placeholder="Email Address">
<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">
<label for="donor_phonename">Mobile Phone (Optional)</label>
<input type="text" name="donor_phonename" id="donor_phonename" value="" maxlength="50" placeholder="Mobile Phone (optional)">
<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 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 field-required">
<span class="field-required"></span>
<label for="billing_addr_street1name">Dirección de la calle:</label>
<input type="text" name="billing_addr_street1name" id="billing_addr_street1name" value="" maxlength="50" placeholder="Address 1">
<input type="hidden" name="billing_addr_street1submit" id="billing_addr_street1submit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_street1', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_street1_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_street2_row" class="form-row form-text">
<div class="form-content">
<label for="billing_addr_street2name">Street 2:</label>
<input type="text" name="billing_addr_street2name" id="billing_addr_street2name" value="" maxlength="50" placeholder="Address 2 (optional)">
<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 field-required">
<span class="field-required"></span>
<label for="billing_addr_cityname">City:</label>
<input type="text" name="billing_addr_cityname" id="billing_addr_cityname" value="" maxlength="50" placeholder="City">
<input type="hidden" name="billing_addr_citysubmit" id="billing_addr_citysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_city', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_city_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_state_row" class="form-row form-selectlist">
<div class="form-content field-required">
<span class="field-required"></span>
<label class="FormLabel" for="billing_addr_state">State/Province:</label>
<select name="billing_addr_state" id="billing_addr_state" size="1" onchange="fire_obs_comp_event('billing_addr_state', this)">
<option>State</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_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 field-required">
<span class="field-required"></span>
<label for="billing_addr_zipname">ZIP/Postal Code:</label>
<input type="text" name="billing_addr_zipname" id="billing_addr_zipname" value="" maxlength="50" placeholder="Zip/Postal Code">
<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 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 Phoenix Children's Foundation.</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>
<h2 class="section-header-container"> Payment Information </h2>
<div class="payment-type-element-container">
<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 field-required">
<span class="field-required"></span>
<label for="responsive_payment_typecc_numbername">Credit Card Number:</label>
<input type="text" name="responsive_payment_typecc_numbername" id="responsive_payment_typecc_numbername" value="" maxlength="22" autocomplete="off" placeholder="Credit Card Number">
<input type="hidden" name="responsive_payment_typecc_numbersubmit" id="responsive_payment_typecc_numbersubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typecc_number', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_number_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('null', new ComponentDisplayer('responsive_payment_typecc_number'));
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typecc_exp_date_row" class="form-row form-date">
<div class="form-content field-required">
<span class="field-required"></span>
<label for="responsive_payment_typecc_exp_date_MONTH">
<span class="label-text">Expiration Date:</span><span class="aural-only">Select month of credit card</span>
</label>
<label for="responsive_payment_typecc_exp_date_YEAR"><span class="aural-only">Select Expiration Year</span></label>
<div class="date-input-container">
<fieldset class="cardExpGroup">
<select name="responsive_payment_typecc_exp_date_MONTH" id="responsive_payment_typecc_exp_date_MONTH" onchange="fire_obs_comp_event('responsive_payment_typecc_exp_date_MONTH', this)">
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8">08</option>
<option value="9">09</option>
<option value="10" selected="selected">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>
<select name="responsive_payment_typecc_exp_date_YEAR" id="responsive_payment_typecc_exp_date_YEAR" onchange="fire_obs_comp_event('responsive_payment_typecc_exp_date_YEAR', this)">
<option value="2024" selected="selected">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
<option value="2027">2027</option>
<option value="2028">2028</option>
<option value="2029">2029</option>
<option value="2030">2030</option>
<option value="2031">2031</option>
<option value="2032">2032</option>
<option value="2033">2033</option>
<option value="2034">2034</option>
</select>
</fieldset>
<input type="hidden" name="responsive_payment_typecc_exp_date_DAY" id="responsive_payment_typecc_exp_date_DAY" value="1">
<script type="text/javascript">
<!--
var comp1 = new ObservableComponent('responsive_payment_typecc_exp_date_MONTH', '');
comp1.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_exp_date_Row', _display);
this.disable_submit_flag(_hidden);
}
var comp2 = new ObservableComponent('responsive_payment_typecc_exp_date_YEAR', '');
comp2.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_exp_date_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script><noscript> </noscript>
</div>
<input type="hidden" name="responsive_payment_typecc_exp_datesubmit" id="responsive_payment_typecc_exp_datesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typecc_exp_date', 'input');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_exp_date_row', _display);
disable_submit_flag('responsive_payment_typecc_exp_datesubmit', _hidden);
}
comp.disable = function(_disabled) {
disable_element('responsive_payment_typecc_exp_date_MONTH', _disabled);
disable_element('responsive_payment_typecc_exp_date_DAY', _disabled);
disable_element('responsive_payment_typecc_exp_date_YEAR', _disabled);
disable_element('responsive_payment_typecc_exp_date_HOUR12', _disabled);
disable_element('responsive_payment_typecc_exp_date_HOUR24', _disabled); //For UK, 24 hour clock used
disable_element('responsive_payment_typecc_exp_date_MINUTE', _disabled);
disable_element('responsive_payment_typecc_exp_date_AMPM', _disabled);
}
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typecc_cvv_row" class="form-row form-text cvv-input">
<div class="form-content field-required">
<span class="field-required"></span>
<label for="responsive_payment_typecc_cvvname">
<span class="FormLabelText">CVV Number:</span>
</label>
<a href="http://help.convio.net/site/PageServer?s_site=pch&pagename=user_donation_cvv" class="HelpLink" title="What is this? Opens new window.">What is this?</a>
<input type="text" name="responsive_payment_typecc_cvvname" id="responsive_payment_typecc_cvvname" value="" maxlength="4" autocomplete="cc-csc" placeholder="CVV Number">
<input type="hidden" name="responsive_payment_typecc_cvvsubmit" id="responsive_payment_typecc_cvvsubmit" value="true">
<script type="text/javascript">
//chrome is mapping cvv as card name
if (/CriOS/.test(navigator.userAgent) || (/Chrome/.test(navigator.userAgent) && /Google Inc/.test(navigator.vendor))) {
document.getElementById('responsive_payment_typecc_cvvname').autocomplete = 'cc-csc';
}
var comp = new ObservableComponent('responsive_payment_typecc_cvv', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_cvv_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
</div>
<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 id="donor_remember_me_row" class="form-row form-checkbox">
<div class="form-content">
<input type="checkbox" name="donor_remember_mename" id="donor_remember_mename" checked="checked" onclick="fire_obs_comp_event('donor_remember_me', this);">
<label for="donor_remember_mename">Save me time in the future and remember me on this computer.</label>
<input type="hidden" name="donor_remember_mesubmit" id="donor_remember_mesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_remember_me', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_remember_me_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('donor_remember_mename')) {
document.getElementById('donor_remember_mename').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('donor_remember_mename')) {
return document.getElementById('donor_remember_mename').checked;
}
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
</div>
</div>
<div class="custom-field-container form-row ">
<div class="form-content">
<div class="form-input-label-block">
<label for="null_dropdown">I want my gift to support</label>
</div>
<select name="null_dropdown" id="null_dropdown" size="1">
<option>I want my gift to support</option>
<option value="Center for Cancer and Blood Disorders">Quiero mi regalo para apoyar</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('null_dropdown', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('null_dropdown_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="nullsubmit" id="nullsubmit" value="true">
</div>
</div>
<div class="custom-field-container form-row ">
<div class="form-content">
<div class="form-input-label-block">
<label for="null_input">Notas sobre tu regalo (opcional):</label>
</div>
<input type="text" name="null_input" id="null_input" value="" maxlength="255" placeholder="Notes about your gift (optional)">
<input type="hidden" name="nullsubmit" id="nullsubmit" value="true">
</div>
</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">Sí, este es un regalo de honor o conmemorativo.</label>
<input type="hidden" name="tribute_show_honor_fieldssubmit" id="tribute_show_honor_fieldssubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_show_honor_fields', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_show_honor_fields_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('tribute_show_honor_fieldsname')) {
document.getElementById('tribute_show_honor_fieldsname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('tribute_show_honor_fieldsname')) {
return document.getElementById('tribute_show_honor_fieldsname').checked;
}
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_type_row" class="form-row form-selectlist" style="display: none;">
<div class="form-content">
<label class="FormLabel" for="tribute_type">Honor Gift Type:</label>
<select name="tribute_type" id="tribute_type" size="1">
<option>Honor Gift Type</option>
<option value="tribute_type_value1">In Memory of</option>
<option value="tribute_type_value2">In Honor of</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('tribute_type', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_type_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="tribute_typesubmit_skip" id="tribute_typesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_type', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_type_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_type'));
function tribute_type_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('tribute_type', src);
}
}
var el = document.getElementById('tribute_type');
if (el) {
Utils.addEvent(el, 'change', tribute_type_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_honoree_name_row" class="form-row form-text" style="display: none;">
<div class="form-content field-required">
<span class="field-required"></span>
<label for="tribute_honoree_namename">Honoree Name:</label>
<input type="text" name="tribute_honoree_namename" id="tribute_honoree_namename" value="" maxlength="50" placeholder="Honoree Name">
<input type="hidden" name="tribute_honoree_namesubmit_skip" id="tribute_honoree_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_honoree_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_honoree_name_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_honoree_name'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_name_row" class="form-row form-text" style="display: none;">
<div class="form-content field-required">
<span class="field-required"></span>
<label for="tribute_notify_recip_namename">Notification Recipient Name:</label>
<input type="text" name="tribute_notify_recip_namename" id="tribute_notify_recip_namename" value="" maxlength="70" placeholder="Person to Notify">
<input type="hidden" name="tribute_notify_recip_namesubmit_skip" id="tribute_notify_recip_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_name_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_name'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_street1_row" class="form-row form-text" style="display: none;">
<div class="form-content field-required">
<span class="field-required"></span>
<label for="tribute_notify_recip_street1name">Notification Recipient Street 1:</label>
<input type="text" name="tribute_notify_recip_street1name" id="tribute_notify_recip_street1name" value="" maxlength="50" placeholder="Notification Street 1">
<input type="hidden" name="tribute_notify_recip_street1submit_skip" id="tribute_notify_recip_street1submit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_street1', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_street1_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_street1'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_street2_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<label for="tribute_notify_recip_street2name">Notification Recipient Street 2:</label>
<input type="text" name="tribute_notify_recip_street2name" id="tribute_notify_recip_street2name" value="" maxlength="50" placeholder="Notification Street 2">
<input type="hidden" name="tribute_notify_recip_street2submit_skip" id="tribute_notify_recip_street2submit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_street2', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_street2_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_street2'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_city_row" class="form-row form-text" style="display: none;">
<div class="form-content field-required">
<span class="field-required"></span>
<label for="tribute_notify_recip_cityname">Notification Recipient City:</label>
<input type="text" name="tribute_notify_recip_cityname" id="tribute_notify_recip_cityname" value="" maxlength="50" placeholder="Notification City">
<input type="hidden" name="tribute_notify_recip_citysubmit_skip" id="tribute_notify_recip_citysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_city', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_city_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_city'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_state_row" class="form-row form-selectlist" style="display: none;">
<div class="form-content field-required">
<span class="field-required"></span>
<label class="FormLabel" for="tribute_notify_recip_state">Notification Recipient State/Province:</label>
<select name="tribute_notify_recip_state" id="tribute_notify_recip_state" size="1" onchange="fire_obs_comp_event('tribute_notify_recip_state', this)">
<option>Notification State</option>
<option value="AK">AK - Alaska</option>
<option value="AL">AL - Alabama</option>
<option value="AR">AR - Arkansas</option>
<option value="AZ">AZ - Arizona</option>
<option value="CA">CA - California</option>
<option value="CO">CO - Colorado</option>
<option value="CT">CT - Connecticut</option>
<option value="DC">DC - District of Columbia</option>
<option value="DE">DE - Delaware</option>
<option value="FL">FL - Florida</option>
<option value="GA">GA - Georgia</option>
<option value="HI">HI - Hawaii</option>
<option value="IA">IA - Iowa</option>
<option value="ID">ID - Idaho</option>
<option value="IL">IL - Illinois</option>
<option value="IN">IN - Indiana</option>
<option value="KS">KS - Kansas</option>
<option value="KY">KY - Kentucky</option>
<option value="LA">LA - Louisiana</option>
<option value="MA">MA - Massachusetts</option>
<option value="MD">MD - Maryland</option>
<option value="ME">ME - Maine</option>
<option value="MI">MI - Michigan</option>
<option value="MN">MN - Minnesota</option>
<option value="MO">MO - Missouri</option>
<option value="MS">MS - Mississippi</option>
<option value="MT">MT - Montana</option>
<option value="NC">NC - North Carolina</option>
<option value="ND">ND - North Dakota</option>
<option value="NE">NE - Nebraska</option>
<option value="NH">NH - New Hampshire</option>
<option value="NJ">NJ - New Jersey</option>
<option value="NM">NM - New Mexico</option>
<option value="NV">NV - Nevada</option>
<option value="NY">NY - New York</option>
<option value="OH">OH - Ohio</option>
<option value="OK">OK - Oklahoma</option>
<option value="OR">OR - Oregon</option>
<option value="PA">PA - Pennsylvania</option>
<option value="RI">RI - Rhode Island</option>
<option value="SC">SC - South Carolina</option>
<option value="SD">SD - South Dakota</option>
<option value="TN">TN - Tennessee</option>
<option value="TX">TX - Texas</option>
<option value="UT">UT - Utah</option>
<option value="VA">VA - Virginia</option>
<option value="VT">VT - Vermont</option>
<option value="WA">WA - Washington</option>
<option value="WI">WI - Wisconsin</option>
<option value="WV">WV - West Virginia</option>
<option value="WY">WY - Wyoming</option>
<option value="AS">AS - American Samoa</option>
<option value="FM">FM - Federated States of Micronesia</option>
<option value="GU">GU - Guam</option>
<option value="MH">MH - Marshall Islands</option>
<option value="MP">MP - Northern Mariana Islands</option>
<option value="PR">PR - Puerto Rico</option>
<option value="PW">PW - Palau</option>
<option value="VI">VI - Virgin Islands</option>
<option value="AA">AA - Armed Forces Americas</option>
<option value="AE">AE - Armed Forces</option>
<option value="AP">AP - Armed Forces Pacific</option>
<option value="AB">AB - Alberta</option>
<option value="BC">BC - British Columbia</option>
<option value="MB">MB - Manitoba</option>
<option value="NB">NB - New Brunswick</option>
<option value="NL">NL - Newfoundland and Labrador</option>
<option value="NS">NS - Nova Scotia</option>
<option value="NT">NT - Northwest Territories</option>
<option value="NU">NU - Nunavut</option>
<option value="ON">ON - Ontario</option>
<option value="PE">PE - Prince Edward Island</option>
<option value="QC">QC - Quebec</option>
<option value="SK">SK - Saskatchewan</option>
<option value="YT">YT - Yukon</option>
<option value="None">None</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('tribute_notify_recip_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_state_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="tribute_notify_recip_statesubmit_skip" id="tribute_notify_recip_statesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_state_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_state'));
function tribute_notify_recip_state_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('tribute_notify_recip_state', src);
}
}
var el = document.getElementById('tribute_notify_recip_state');
if (el) {
Utils.addEvent(el, 'change', tribute_notify_recip_state_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_zip_row" class="form-row form-text" style="display: none;">
<div class="form-content field-required">
<span class="field-required"></span>
<label for="tribute_notify_recip_zipname">Notification Recipient ZIP/Postal Code:</label>
<input type="text" name="tribute_notify_recip_zipname" id="tribute_notify_recip_zipname" value="" maxlength="50" placeholder="Notification Zip Code">
<input type="hidden" name="tribute_notify_recip_zipsubmit_skip" id="tribute_notify_recip_zipsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_zip', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_zip_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_zip'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_country_row" class="form-row form-selectlist" style="display: none;">
<div class="form-content field-required">
<span class="field-required"></span>
<label class="FormLabel" for="tribute_notify_recip_country">Notification Recipient Country:</label>
<select name="tribute_notify_recip_country" id="tribute_notify_recip_country" size="1" onchange="fire_obs_comp_event('tribute_notify_recip_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>
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Elige el monto de tu donación DONACIÓN ÚNICA DONACIÓN MENSUAL Field Is Required Choose Your Gift Amount $50 $100 $250 $500 $1000 $5 $10 $25 $50 $100 Other Enter amount Yes, automatically repeat this gift every month. DA UN PASO ADELANTE. DETÉN EL CÁNCER. Únete a la lucha contra el cáncer infantil. El Centro para el Cáncer y Trastornos Sanguíneos de Phoenix Children's trata a miles de jóvenes pacientes con cáncer cada año. Nuestra misión es asegurar que reciban la mejor atención desde el momento del diagnóstico hasta la finalización del tratamiento y más allá. Tu donación hoy nos ayuda a brindar atención de calidad mundial a los pacientes, ofrecer terapias de vanguardia y realizar investigaciones que conducen a avances que salvan vidas. INFORMACIÓN DEL DONANTE Primer Nombre: Apellido: Dirección de correo electrónico Mobile Phone (Optional) 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 Required Dirección de la calle: Street 2: City: State/Province: State AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida GA - Georgia HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming AS - American Samoa FM - Federated States of Micronesia GU - Guam MH - Marshall Islands MP - Northern Mariana Islands PR - Puerto Rico PW - Palau VI - Virgin Islands AA - Armed Forces Americas AE - Armed Forces AP - Armed Forces Pacific AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NL - Newfoundland and Labrador NS - Nova Scotia NT - Northwest Territories NU - Nunavut ON - Ontario PE - Prince Edward Island QC - Quebec SK - Saskatchewan YT - Yukon None Required ZIP/Postal Code: If you donate and have not already registered, you will receive periodic updates and communications from Phoenix Children's Foundation. PAYMENT INFORMATION CREDIT CARD INFORMATION: Credit Card Type: * * * * Credit Card Number: Expiration Date:Select month of credit card Select Expiration Year 01 02 03 04 05 06 07 08 09 10 11 12 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 CVV Number: What is this? Save me time in the future and remember me on this computer. I want my gift to support I want my gift to supportQuiero mi regalo para apoyar Required Notas sobre tu regalo (opcional): Sí, este es un regalo de honor o conmemorativo. Honor Gift Type: Honor Gift Type In Memory of In Honor of Required Honoree Name: Notification Recipient Name: Notification Recipient Street 1: Notification Recipient Street 2: Notification Recipient City: Notification Recipient State/Province: Notification State AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida GA - Georgia HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming AS - American Samoa FM - Federated States of Micronesia GU - Guam MH - Marshall Islands MP - Northern Mariana Islands PR - Puerto Rico PW - Palau VI - Virgin Islands AA - Armed Forces Americas AE - Armed Forces AP - Armed Forces Pacific AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NL - Newfoundland and Labrador NS - Nova Scotia NT - Northwest Territories NU - Nunavut ON - Ontario PE - Prince Edward Island QC - Quebec SK - Saskatchewan YT - Yukon None Required Notification Recipient ZIP/Postal Code: Notification Recipient 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. 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