secure.fredhutch.org
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URL:
https://secure.fredhutch.org/site/SPageServer?pagename=adf_agiv&experience=YEMatch23&s_src=december23&s_subsrc=aegeo23121&fh_...
Submission: On December 02 via manual from US — Scanned from US
Submission: On December 02 via manual from US — Scanned from US
Form analysis 1 forms found in the DOM
<form id="donate_form" novalidate="novalidate">
<input type="hidden" value="donate" name="method" id="donate_api_method">
<input type="hidden" value="1.0" name="v">
<input type="hidden" name="extproc" id="inptextproc" value="paypal" disabled="">
<input type="hidden" name="extproc2" id="inptextproc2" value="amazon" disabled="">
<input type="hidden" name="payment_confirmation_id" value="">
<input type="hidden" name="donation_level_selected" id="donation_level_selected" value="100">
<input type="hidden" name="lo_form_name" value="API Donation Forms: Digital Wallet Payment - aegeo23121">
<input type="hidden" name="lo_source_code" value="december23">
<input type="hidden" name="lo_subsource_code" value="aegeo23121">
<input type="hidden" value="https://secure.fredhutch.org/site/SPageServer?pagename=YEMatch23_thanks&experience=YEMatch23" name="finish_success_redirect" id="finish_success_redirect" disabled="">
<input type="hidden" value="https://secure.fredhutch.org/site/SPageServer?pagename=adf_agiv_error&experience=YEMatch23" name="finish_error_redirect" id="finish_error_redirect" disabled="">
<input type="hidden" value="6480" name="form_id">
<input type="hidden" value="true" name="validate">
<div class="cddevDonationLevelsRow rowflex columnflex-mobile donate-row section-padding-top-36px section-padding-bottom-56px">
<div id="donation_information" class="cell collapse">
<div class="rowflex columnflex-mobile">
<div class="cell small-twelve align-center">
<h4 class="section-header donate-xs-col-12">Choose Gift Amount <div class="secure">
<svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="753.23px" height="753.23px" viewBox="0 0 753.23 753.23" style="enable-background:new 0 0 753.23 753.23;"
xml:space="preserve">
<path
d="M635.538,282.461h-70.615v-94.154C564.923,84.314,480.608,0,376.615,0C272.623,0,188.308,84.291,188.308,188.308v94.154h-70.615c-25.987,0-47.077,21.09-47.077,47.077v376.615c0,26.011,21.09,47.077,47.077,47.077h517.846c26.01,0,47.077-21.09,47.077-47.077V329.538C682.615,303.528,661.548,282.461,635.538,282.461z M258.923,188.308c0-64.896,52.797-117.692,117.692-117.692s117.692,52.797,117.692,117.692v94.154H258.923V188.308z M612,682.615H141.23V353.077H612V682.615z">
</path>
</svg> Secure
</div>
</h4>
<fieldset id="donation_amounts" class="selection-buttons donate-xs-col-12">
<div class="donation-button-container selection-button-container donation-level-1 no-margin-left">
<div class="selection-button-inner">
<label for="level_amt_5000" class="donation-amount-button selection-button">
<input type="radio" name="level_id" id="level_amt_5000" value="8967">
<span class="selection-button-text">$5,000</span>
</label>
</div>
</div>
<div class="donation-button-container selection-button-container donation-level-2">
<div class="selection-button-inner">
<label for="level_amt_1000" class="donation-amount-button selection-button">
<input type="radio" name="level_id" id="level_amt_1000" value="8966">
<span class="selection-button-text">$1,000</span>
</label>
</div>
</div>
<div class="donation-button-container selection-button-container donation-level-3">
<div class="selection-button-inner">
<label for="level_amt_500" class="donation-amount-button selection-button">
<input type="radio" name="level_id" id="level_amt_500" value="8965">
<span class="selection-button-text">$500</span>
</label>
</div>
</div>
<div class="donation-button-container selection-button-container donation-level-4">
<div class="selection-button-inner">
<label for="level_amt_250" class="donation-amount-button selection-button">
<input type="radio" name="level_id" id="level_amt_250" value="8961">
<span class="selection-button-text">$250</span>
</label>
</div>
</div>
<div class="donation-button-container selection-button-container donation-level-5">
<div class="selection-button-inner">
<label for="level_amt_100" class="donation-amount-button selection-button selected">
<input type="radio" name="level_id" id="level_amt_100" value="8963">
<span class="selection-button-text">$100</span>
</label>
</div>
</div>
<div class="donation-button-container selection-button-container donation-level-6">
<div class="selection-button-inner">
<label for="level_amt_50" class="donation-amount-button selection-button">
<input type="radio" name="level_id" id="level_amt_50" value="8964">
<span class="selection-button-text">$50</span>
</label>
</div>
</div>
<div class="donation-button-container donation-other-container selection-button-container donation-level-7">
<div class="selection-button-inner">
<label for="level_amt_other" class="donation-amount-button donation-amount-other-button selection-button">
<input type="radio" name="level_id" id="level_amt_other" value="8962">
<span class="selection-button-text" id="level_amt_other_words">Custom</span>
<span class="selection-button-text" id="level_amt_other_value" style="display:none;">
<span>$</span><input type="text" disabled="" name="other_amount" id="level_amt_other_input" required="" data-rule-min="5" data-rule-number="true" aria-required="true">
</span>
</label>
</div>
</div>
</fieldset>
<fieldset id="fake_donation_amounts" class="selection-buttons donate-xs-col-12" style="display: none;">
<div class="donation-button-container selection-button-container donation-level-1" style="display:none;">
<div class="selection-button-inner">
<label for="" class="donation-amount-button selection-button">
<input type="radio" name="fake_level_id" id="" value="">
<span class="selection-button-text">$</span>
</label>
</div>
</div>
<div class="donation-button-container selection-button-container donation-level-2" style="display:none;">
<div class="selection-button-inner">
<label for="" class="donation-amount-button selection-button">
<input type="radio" name="fake_level_id" id="" value="">
<span class="selection-button-text">$</span>
</label>
</div>
</div>
<div class="donation-button-container selection-button-container donation-level-3" style="display:none;">
<div class="selection-button-inner">
<label for="" class="donation-amount-button selection-button">
<input type="radio" name="fake_level_id" id="" value="">
<span class="selection-button-text">$</span>
</label>
</div>
</div>
<div class="donation-button-container selection-button-container donation-level-4" style="display:none;">
<div class="selection-button-inner">
<label for="" class="donation-amount-button selection-button">
<input type="radio" name="fake_level_id" id="" value="">
<span class="selection-button-text">$</span>
</label>
</div>
</div>
<div class="donation-button-container selection-button-container donation-level-5" style="display:none;">
<div class="selection-button-inner">
<label for="" class="donation-amount-button selection-button">
<input type="radio" name="fake_level_id" id="" value="">
<span class="selection-button-text">$</span>
</label>
</div>
</div>
<div class="donation-button-container donation-other-container selection-button-container donation-level-6" style="display:none;">
<div class="selection-button-inner">
<label for="fake_level_amt_other" class="donation-amount-button donation-amount-other-button selection-button">
<input type="radio" name="fake_level_id" id="fake_level_amt_other" value="">
<span class="selection-button-text" id="fake_level_amt_other_words">Custom</span>
<span class="selection-button-text" id="fake_level_amt_other_value" style="display:none;">
<span>$</span><input type="text" disabled="" name="fake_other_amount" id="fake_level_amt_other_input" required="" data-rule-min="" data-rule-number="true" aria-required="true">
</span>
</label>
</div>
</div>
</fieldset>
</div>
</div>
<fieldset>
<div class="rowflex columnflex-mobile section-padding-24px mobile-section-padding-24px ">
<div class="cell small-twelve align-center">
<div class="custom-checkbox-label checkbox-container">
<input type="checkbox" name="level_autorepeat" id="level_autorepeat" value="false">
<label for="level_autorepeat" class="checkbox-label">Yes, make my gift a MONTHLY DONATION</label>
</div>
</div>
</div>
<div class="rowflex columnflex-mobile section-padding-14px no-padding-top mobile-section-padding-14px ">
<div class="cell small-twelve align-center">
<h4 class="section-subheader donate-xs-col-12">Direct My Gift</h4>
<div class="donate-select">
<label for="directed_fund_initial" class="sr-only">Direct My Gift</label>
<select name="directed_fund_initial" id="directed_fund_initial">
<option value="Fred Hutch greatest need" selected="selected">Fred Hutch greatest need</option>
<option value="Cancer research">Cancer research</option>
<option value="Cancer prevention and early detection">Cancer prevention and early detection</option>
<option value="COVID-19 virus and vaccine research">COVID-19 virus and vaccine research</option>
<option value="Data science">Data science</option>
<option value="Diversity, equity and reduction of health disparities">Diversity, equity and reduction of health disparities</option>
<option value="HIV virus and vaccine research">HIV virus and vaccine research</option>
<option value="Immunotherapy">Immunotherapy</option>
<option value="Infectious disease research">Infectious disease research</option>
<option value="Nursing research fund">Nursing research fund</option>
<option value="Patient and family assistance fund">Patient and family assistance fund</option>
<option value="Precision oncology">Precision oncology</option>
<option value="Patient housing">Patient housing</option>
<option value="Supportive care services">Supportive care services</option>
<option value="Other">Other</option>
</select>
</div>
</div>
</div>
<div id="directed_fund_ac_row" class="hidden rowflex columnflex-mobile section-padding-14px no-padding-top mobile-section-padding-14px ">
<div class="cell small-twelve align-center">
<span class="directed-fund-message">Start typing to view directed gift options</span>
<div class="donate-select">
<input type="text" name="directed_fund_autocomplete" id="directed_fund_autocomplete" placeholder="ex. Breast cancer, Leukemia, HSV Gene Therapy">
</div>
</div>
</div>
<div class="hidden rowflex columnflex-mobile section-padding-14px no-padding-top mobile-section-padding-14px ">
<div class="cell small-twelve align-center">
<h4 class="section-subheader donate-xs-col-12">Direct My Gift</h4>
<div class="donate-select">
<select name="directed_fund_option" id="directed_fund_option">
<option value="Fred Hutch greatest need" selected="selected">Fred Hutch greatest need</option>
<option value="Acute lymphoblastic leukemia (ALL)">Acute lymphoblastic leukemia (ALL)</option>
<option value="Acute myeloid leukemia (AML)">Acute myeloid leukemia (AML)</option>
<option value="Basic Science">Basic Science</option>
<option value="Bladder-urologic cancer">Bladder-urologic cancer</option>
<option value="Breast cancer">Breast cancer</option>
<option value="Cervical cancer">Cervical cancer</option>
<option value="Chronic myeloid leukemia (CML)">Chronic myeloid leukemia (CML)</option>
<option value="Colon cancer">Colon cancer</option>
<option value="Cook for Your Life">Cook for Your Life</option>
<option value="Cord blood research">Cord blood research</option>
<option value="Esophageal cancer">Esophageal cancer</option>
<option value="Gastrointestinal cancers">Gastrointestinal cancers</option>
<option value="Global Oncology/Uganda">Global Oncology/Uganda</option>
<option value="Gynecologic cancers">Gynecologic cancers</option>
<option value="Hematologic cancers">Hematologic cancers</option>
<option value="HSV Gene Therapy">HSV Gene Therapy</option>
<option value="Kidney cancer transplant">Kidney cancer transplant</option>
<option value="Kidney/renal cancer">Kidney/renal cancer</option>
<option value="Leukemia">Leukemia</option>
<option value="Lung cancer">Lung cancer</option>
<option value="Lymphoma">Lymphoma</option>
<option value="Melanoma">Melanoma</option>
<option value="Merkel Cell carcinoma">Merkel Cell carcinoma</option>
<option value="Multiple myeloma">Multiple myeloma</option>
<option value="Neurologic cancers">Neurologic cancers</option>
<option value="Ovarian cancer">Ovarian cancer</option>
<option value="Pancreatic cancers">Pancreatic cancers</option>
<option value="Pete Gross House">Pete Gross House</option>
<option value="Prostate cancer">Prostate cancer</option>
<option value="Radiation oncology">Radiation oncology</option>
<option value="Rosemary Ford scholarship fund">Rosemary Ford scholarship fund</option>
<option value="Sarcoma">Sarcoma</option>
<option value="South Lake Union House">South Lake Union House</option>
<option value="Survivorship Program">Survivorship Program</option>
<option value="Thoracic, head, and neck cancers">Thoracic, head, and neck cancers</option>
<option value="Cancer research">Cancer research</option>
<option value="Cancer prevention and early detection">Cancer prevention and early detection</option>
<option value="COVID-19 virus and vaccine research">COVID-19 virus and vaccine research</option>
<option value="Data science">Data science</option>
<option value="Diversity, equity and reduction of health disparities">Diversity, equity and reduction of health disparities</option>
<option value="HIV virus and vaccine research">HIV virus and vaccine research</option>
<option value="Immunotherapy">Immunotherapy</option>
<option value="Infectious disease research">Infectious disease research</option>
<option value="Nursing research fund">Nursing research fund</option>
<option value="Patient and family assistance fund">Patient and family assistance fund</option>
<option value="Precision oncology">Precision oncology</option>
<option value="Patient housing">Patient housing</option>
<option value="Supportive care services">Supportive care services</option>
<option value="Other">Other</option>
</select>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<div class="cddevDedicationRow rowflex columnflex-mobile donate-row section-padding-bottom-56px ">
<div class="cell collapse">
<div class="rowflex columnflex-mobile">
<div class="cell small-twelve align-center">
<h4 class="section-header donate-xs-col-12">Dedication <span id="required_field_ind_help">[* = required] </span></h4>
</div>
</div>
<fieldset id="honor_memorial_options" class="selection-buttons donate-xs-col-12">
<div class="rowflex columnflex-mobile">
<div class="cell small-twelve align-center">
<div class="selection-button-container three-button-container">
<div class="selection-button-inner">
<label for="honor_memorial_none" class="selection-button selected">
<input type="radio" value="" name="tribute.type" id="honor_memorial_none">
<span class="selection-button-text">None</span>
</label>
</div>
</div>
<div class="selection-button-container three-button-container">
<div class="selection-button-inner">
<label for="honor_memorial_honor" class="selection-button">
<input type="radio" value="tribute" name="tribute.type" id="honor_memorial_honor">
<span class="selection-button-text">In Honor of</span>
</label>
</div>
</div>
<div class="selection-button-container three-button-container last-button">
<div class="selection-button-inner">
<label for="honor_memorial_memorial" class="selection-button">
<input type="radio" value="memorial" name="tribute.type" id="honor_memorial_memorial">
<span class="selection-button-text">In Memory of</span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
<div style="display:none;" id="memorial_help_text" class="rowflex columnflex-mobile">
<div class="cell small-twelve align-center">
<div>Choose "In Memory<span class="donate-xs-hidden"> of</span>" only if the person you are honoring is deceased.</div>
</div>
</div>
<div style="display:none;" id="honoree-information" class="rowflex columnflex-mobile section-padding-top-14px mobile-section-padding-top-14px">
<div class="cell collapse small-twelve align-center">
<fieldset>
<div class="rowflex columnflex-mobile section-padding-8px mobile-section-padding-8px">
<div class="cell sixflex small-twelve align-center mobile-margin-bottom-20px">
<label for="honoree_name_first">Honoree First Name *</label>
<input type="text" name="tribute.honoree.name.first" id="honoree_name_first" required="" aria-required="true" disabled="">
</div>
<div class="cell sixflex small-twelve align-center">
<label for="honoree_name_last">Honoree Last Name *</label>
<input type="text" name="tribute.honoree.name.last" id="honoree_name_last" required="" aria-required="true" disabled="">
</div>
</div>
</fieldset>
</div>
</div>
</div>
</div>
<div class="rowflex columnflex-mobile donate-row " id="tribute_card_spacer" style="display: none;"></div>
<div id="tribute_options" class="cddevTributeRow rowflex columnflex-mobile donate-row section-padding-bottom-56px " style="display: none;">
<div class="cell collapse">
<div class="rowflex columnflex-mobile">
<div class="cell small-twelve align-center">
<h4 class="section-header donate-xs-col-12">Tribute Card <span id="required_field_ind_help">[* = required] </span></h4>
</div>
</div>
<div class="rowflex columnflex-mobile">
<div class="cell small-twelve align-center">
<fieldset class="selection-buttons donate-xs-col-12">
<div class="selection-button-container three-button-container">
<div class="selection-button-inner">
<label for="tribute_none" class="selection-button selected">
<input type="radio" value="none" name="tribute_option" id="tribute_none">
<span class="selection-button-text">None</span>
</label>
</div>
</div>
<div class="selection-button-container three-button-container">
<div class="selection-button-inner">
<label for="tribute_print" class="selection-button">
<input type="radio" value="print" name="tribute_option" id="tribute_print">
<span class="selection-button-text selection-button-long-text"><span class="donate-xs-hidden">Send </span>Printed Card</span>
</label>
</div>
</div>
<div class="selection-button-container three-button-container last-button">
<div class="selection-button-inner">
<label for="tribute_ecard" class="selection-button">
<input type="radio" value="ecard" name="tribute_option" id="tribute_ecard">
<span class="selection-button-text"><span class="donate-xs-hidden">Send </span>E-Card</span>
</label>
</div>
</div>
<input type="hidden" name="ecard.send" value="false" id="ecard_send">
</fieldset>
</div>
</div>
<div style="display:none;" id="tribute_print_fields" class="rowflex columnflex-mobile section-padding-14px mobile-section-padding-14px">
<div class="cell collapse small-twelve align-center">
<fieldset>
<div class="rowflex columnflex-mobile section-padding-8px mobile-section-padding-8px">
<div class="cell sixflex small-twelve align-center mobile-margin-bottom-20px">
<label for="tribute_print_name_first">Recipient First Name *</label>
<input type="text" name="tribute.notify.name.first" id="tribute_print_name_first" required="" aria-required="true" disabled="">
</div>
<div class="cell sixflex small-twelve align-center">
<label for="tribute_print_name_last">Recipient Last Name *</label>
<input type="text" name="tribute.notify.name.last" id="tribute_print_name_last" required="" aria-required="true" disabled="">
</div>
</div>
<input type="hidden" name="tribute.notify.name.full" id="tribute_print_name_full" disabled="" value=" ">
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px">
<div class="cell small-twelve align-center">
<label for="tribute_print_address_street1">Street Address Line 1 *</label>
<input type="text" name="tribute.notify.address.street1" id="tribute_print_address_street1" required="" aria-required="true" disabled="">
</div>
</div>
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px">
<div class="cell small-twelve align-center">
<div class="show-street-2-fields hide">
<label for="tribute_print_address_street2">Street Address Line 2</label>
<input type="text" name="tribute.notify.address.street2" id="tribute_print_address_street2" disabled="">
</div>
<a class="show-street-2 display-block size-18px" href="#"><span class="show-street-2-span">+</span><span class="hide-street-2-span hide">-</span> Street Address Line 2 (optional)</a>
</div>
</div>
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px">
<div class="cell fourflex small-twelve align-center mobile-margin-bottom-20px">
<label for="tribute_print_address_city">City *</label>
<input type="text" name="tribute.notify.address.city" id="tribute_print_address_city" required="" aria-required="true" disabled="">
</div>
<div class="cell fourflex small-twelve align-center mobile-margin-bottom-20px">
<div class="donate-select">
<label for="tribute_print_address_state">State/Province *</label>
<select name="tribute.notify.address.state" id="tribute_print_address_state" required="" aria-required="true" disabled="">
<option value="" selected=""></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">HA - 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">AE - 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="NF">NF - 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>
</div>
</div>
<div class="cell fourflex small-twelve align-center">
<label for="tribute_print_address_zip">ZIP/Postal Code *</label>
<input type="text" name="tribute.notify.address.zip" id="tribute_print_address_zip" required="" aria-required="true" disabled="">
</div>
</div>
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px">
<div class="cell small-twelve align-center">
<div class="donate-select">
<label for="tribute_print_address_country">Country</label>
<select name="tribute.notify.address.country" id="tribute_print_address_country" disabled="">
<option value="" selected="">Country</option>
<option value="United States" selected="">United States</option>
<option value="United Kingdom">United Kingdom</option>
<option value="Afghanistan">Afghanistan</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="Bolivia">Bolivia</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="Congo, The Democratic Republic of The">Congo, The Democratic Republic of The</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="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</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="Fiji">Fiji</option>
<option value="Finland">Finland</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="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="Iran, Islamic Republic of">Iran, Islamic Republic of</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Korea, Democratic People's Republic of">Korea, Democratic People's Republic of</option>
<option value="Korea, Republic of">Korea, Republic of</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="Libyan Arab Jamahiriya">Libyan Arab Jamahiriya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macao">Macao</option>
<option value="Macedonia, The Former Yugoslav Republic of">Macedonia, The Former Yugoslav Republic of</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="Micronesia, Federated States of">Micronesia, Federated States of</option>
<option value="Moldova, Republic of">Moldova, Republic of</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</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="Netherlands Antilles">Netherlands Antilles</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="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</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 Helena">Saint Helena</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</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 and Montenegro">Serbia and Montenegro</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</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 Georgia and The South Sandwich Islands">South Georgia and The South Sandwich Islands</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="Tanzania, United Republic of">Tanzania, United Republic of</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 States">United States</option>
<option value="United States Minor Outlying Islands">United States Minor Outlying Islands</option>
<option value="Uruguay">Uruguay</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Venezuela">Venezuela</option>
<option value="Viet Nam">Viet Nam</option>
<option value="Virgin Islands, British">Virgin Islands, British</option>
<option value="Virgin Islands, U.S.">Virgin Islands, U.S.</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>
</div>
</div>
</div>
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px">
<div class="cell small-twelve align-center">
<label for="tribute_message">Personal Message</label>
<label id="tribute_message_length_warning" class="error" for="tribute_message" style="display:none;"> <span aria-hidden="true" class="donate-exclamation-mark"><img src="../img/warning_exclamation.png"></span><span
class="sr-only">Error:</span> The maximum length of your message is 255 characters.</label>
<textarea name="ecard.message" id="tribute_message" rows="3" maxlength="255" data-maxlength="255" disabled=""></textarea>
</div>
</div>
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px">
<div class="cell small-twelve align-center">
<div class="donate-xs-col-12">
<label for="tribute_print_closing">Closing signature</label>
<input type="text" name="tribute.message.signature" id="tribute_print_closing" disabled="">
</div>
</div>
</div>
</fieldset>
<fieldset>
<div class="rowflex hold section-padding-12px mobile-section-padding-12px donate-xs-hidden">
<div class="cell fourflex align-center">
<p class="font-medium margin-bottom-8px">Preview Front</p>
<a href="#ecard_front" class="ecard-preview" rel="modal:open">
<img class="img-responsive" src="../img/honor-card-front-preview.jpg" id="ecard_front_honor_pvw">
<img class="img-responsive" src="../img/memory-card-front-preview.jpg" id="ecard_front_memorial_pvw" style="display:none;">
</a>
</div>
<div class="cell fourflex align-center">
<p class="font-medium margin-bottom-8px">Preview Inside</p>
<a href="#ecard_inside" class="ecard-preview" rel="modal:open">
<img class="img-responsive" src="../img/honor-card-inside-preview.jpg" id="ecard_inside_honor_pvw">
<img class="img-responsive" src="../img/memory-card-inside-preview.jpg" id="ecard_inside_memorial_pvw" style="display:none;">
</a>
</div>
<div class="cell fourflex align-center">
<p class="font-medium margin-bottom-8px">Preview Back</p>
<a href="#ecard_back" class="ecard-preview" rel="modal:open">
<img class="img-responsive" src="../img/honor-card-back-preview.jpg" id="ecard_back_honor_pvw">
<img class="img-responsive" src="../img/memory-card-back-preview.jpg" id="ecard_back_memorial_pvw" style="display:none;">
</a>
</div>
</div>
</fieldset>
</div>
</div>
<div style="display:none;" id="tribute_ecard_fields" class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px">
<div class="cell small-twelve align-center">
<fieldset>
<p class="font-medium size-18px section-margin-14px margin-bottom-none">The E-Card is a digital version of our printed card.</p>
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px">
<div class="cell small-twelve align-center collapse">
<label for="tribute_ecard_recipients">Recipient's Email Address *</label>
<input type="text" name="ecard.recipients" id="tribute_ecard_recipients" required="" aria-required="true" disabled="">
</div>
</div>
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px">
<div class="cell small-twelve align-center collapse">
<label for="tribute_ecard_subject">E-Card Subject Line *</label>
<input type="text" name="ecard.subject" id="tribute_ecard_subject" required="" aria-required="true" disabled="">
</div>
</div>
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px">
<div class="cell small-twelve align-center collapse">
<label for="tribute_ecard_message">E-Card Message *</label>
<label id="tribute_ecard_message_length_warning" class="error" for="tribute_ecard_message" style="display:none;"> <span aria-hidden="true" class="donate-exclamation-mark"><img src="../img/warning_exclamation.png"></span><span
class="sr-only">Error:</span> The maximum length of your message is 255 characters.</label>
<textarea name="ecard.message" id="tribute_ecard_message" rows="3" required="" maxlength="255" data-maxlength="255" aria-required="true" disabled=""></textarea>
</div>
</div>
<input type="hidden" id="ecard_id" name="ecard.id" value="" disabled="">
</fieldset>
</div>
</div>
</div>
</div>
<div class="cddevPaymentRow rowflex columnflex-mobile donate-row section-padding-bottom-56px">
<div class="cell collapse">
<div class="rowflex columnflex-mobile">
<div class="cell small-twelve align-center">
<h4 class="section-header donate-xs-col-12">Payment <span id="required_field_ind_help">[* = required] </span></h4>
</div>
</div>
<div class="rowflex columnflex-mobile">
<div class="cell small-twelve align-center">
<fieldset id="payment_type_options" class="selection-buttons donate-xs-col-12">
<div class="selection-button-container three-button-container four-button-container">
<div class="selection-button-inner">
<label for="payment_type_credit" class="selection-button selected">
<input type="radio" value="credit" name="payment_type" id="payment_type_credit">
<span id="payment_type_credit_span" class="selection-button-text selection-button-long-text">
<span class="show-desktop ">Credit/Debit Card</span>
<span class="show-mobile ccMobile">Credit/</span><br><span class="show-mobile ">Debit</span><br><span class="show-mobile">Card</span>
</span>
</label>
</div>
</div>
<div class="selection-button-container three-button-container four-button-container amazon-pay ">
<div class="selection-button-inner">
<label for="payment_type_amazon" class="selection-button">
<input type="radio" value="amazonPay" name="payment_type" id="payment_type_amazon">
<span class="selection-button-text"><img src="https://secure2.convio.net/fhcrc/images/content/pagebuilder/mark-amazon-pay.png" alt="Amazon Pay"></span>
</label>
</div>
</div>
<div class="selection-button-container three-button-container four-button-container">
<div class="selection-button-inner">
<label for="payment_type_ach" class="selection-button">
<input type="radio" value="ach" name="payment_type" id="payment_type_ach">
<span id="payment_type_ach_text" class="selection-button-text selection-button-long-text">Check</span>
</label>
</div>
</div>
<div class="selection-button-container three-button-container four-button-container paypal-button last-button">
<div class="selection-button-inner">
<label for="payment_type_paypal" class="selection-button">
<input type="radio" value="paypal" name="payment_type" id="payment_type_paypal">
<span class="selection-button-text"><img src="https://secure2.convio.net/fhcrc/images/content/pagebuilder/mark-paypal.png" alt="PayPal"></span>
</label>
</div>
</div>
</fieldset>
</div>
</div>
<div style="" id="payment_credit_fields">
<div class="rowflex columnflex-mobile">
<div class="cell collapse">
<fieldset>
<div class="rowflex columnflex-mobile section-padding-14px mobile-section-padding-14px">
<div class="cell sixflex small-twelve align-center mobile-margin-bottom-20px relative">
<label for="payment_credit_card_num">Card Number *</label>
<input class="credit-card-number" type="text" name="card_number" id="payment_credit_card_num" placeholder="XXXX XXXX XXXX XXXX" pattern="[0-9]*" maxlength="19" required="" data-rule-creditcard="true" aria-required="true">
<ul class="card_logos">
<li class="card_visa"><img src="../cddev_lo_assets/images/cc-visa.png" alt="Visa"></li>
<li class="card_mastercard"><img src="../cddev_lo_assets/images/cc-mc.png" alt="Mastercard"></li>
<li class="card_amex"><img src="../cddev_lo_assets/images/cc-amex.png" alt="American Express"></li>
<li class="card_discover"><img src="../cddev_lo_assets/images/cc-disc.png" alt="Discover"></li>
</ul>
</div>
<div class="cc-date cell small-twelve align-center mobile-margin-bottom-20px">
<div class="donate-select">
<label for="payment_credit_card_exp_month">Expiration Month *</label>
<select name="card_exp_date_month" id="payment_credit_card_exp_month" required="" aria-required="true">
<option value="">MM</option>
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8">08</option>
<option value="9">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>
</div>
</div>
<div class="cc-date cell small-twelve align-center mobile-margin-bottom-20px">
<div class="donate-select">
<label for="payment_credit_card_exp_year">Expiration Year *</label>
<select name="card_exp_date_year" id="payment_credit_card_exp_year" required="" aria-required="true">
<option value="">YYYY</option>
<option value="2022">2022</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>
<option value="2032">2032</option>
</select>
</div>
</div>
<div class="cell small-twelve align-center">
<label for="payment_credit_card_cvv">Security Code * <span id="whats_this_cvv_help"
class="whatsthis right mobile-float-none mobile-margin-left-1-percent"><a title="What is this?" class="HelpLink" href="http://help.convio.net/site/PageServer?s_site=fhcrc&pagename=user_donation_cvv" target="_blank"><span>What's this?</span><!-- <span class="show-mobile size-24px-mobile"><i class="far fa-question-circle"></i></span> --></a></span></label>
<input class="security-code" type="number" name="card_cvv" id="payment_credit_card_cvv" placeholder="XXX" required="" aria-required="true">
</div>
</div>
</fieldset>
</div>
</div>
</div>
<fieldset style="display:none;" id="payment_ach_fields" class="rowflex columnflex-mobile section-padding-14px mobile-section-padding-14px">
<div class="rowflex columnflex-mobile section-padding-8px mobile-section-padding-8px">
<div class="cell fourflex small-twelve align-center mobile-margin-bottom-20px">
<label for="payment_ach_routing">Bank Routing Number * <span id="whats_this_ach_help"
class="whatsthis margin-left-2-percent mobile-margin-left-1-percent"><a class="HelpLink" href="http://help.convio.net/site/PageServer?s_site=fhcrc&pagename=User_Donation_ACH" target="_blank"><span>What's this?</span><!-- <span class="show-mobile size-24px-mobile"><i class="far fa-question-circle"></i></span> --></a></span></label>
<input type="text" name="ach_routing" id="payment_ach_routing" required="" aria-required="true" disabled="">
</div>
<div class="cell fourflex small-twelve align-center mobile-margin-bottom-20px">
<label for="payment_ach_account">Bank Account Number *</label>
<input type="text" name="ach_account" id="payment_ach_account" required="" aria-required="true" disabled="">
</div>
<div class="cell fourflex small-twelve align-center mobile-margin-bottom-20px">
<label for="payment_ach_account_verify">Verify Bank Account Number *</label>
<input type="text" name="ach_account_verify" id="payment_ach_account_verify" required="" data-rule-equalto="#payment_ach_account" aria-required="true" disabled="">
</div>
</div>
<div class="rowflex columnflex-mobile section-padding-14px mobile-section-padding-14px">
<div class="cell small-twelve align-center">
<div id="ach_authorize_container">
<input type="checkbox" name="ach_authorize" id="ach_authorize" required="" aria-required="true" disabled="" value="false">
<label for="ach_authorize" class="checkbox-label" id="ach_auth_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.</label>
</div>
</div>
</div>
</fieldset>
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px amazon " style="display: none;">
<div class="cell small-twelve align-center">
<fieldset>
<input type="hidden" name="AmazonBillingAgreementId" value="">
<input type="hidden" name="AmazonOrderReferenceId" value="">
<input type="hidden" name="AmazonAccessToken" value="">
<input type="hidden" name="AmazonPaymentSelected" value="">
<div id="AmazonPayment" style="display: none; margin-right: 22px;">
<div id="AmazonLogin">Please login to Amazon before continuing:</div>
<div id="AmazonPayButton" data-treatment="{"treatment":"T15","abtestName":"BUTTON_REBRANDING"}">
<div id="apay-tooltip-display-parent" style="position: relative; display: inline-block"><img class=" amazonpay-button-inner-image" style="cursor:pointer; max-height:60px;" alt="AmazonPay" id="OffAmazonPaymentsWidgets0" tabindex="0"
src="https://d2ldlvi1yef00y.cloudfront.net/default/us/live/lwa/gold/large/PwA.png"><span class="apay-tooltip-display-content" style="position: absolute; top: 50px; z-index: 999; font-family: Arial, Helvetica, sans-serif; max-width: 150px; width: 150px; min-height: 45px; color: white; border-radius: 6px; padding: 10px; border: 1px solid black;
background-color: rgb(47, 55, 61); line-height: normal; text-align: center; font-size: 14px; ">Speed through checkout using the addresses and payment methods saved in your Amazon account</span></div>
<style>
#AmazonPayButton .apay-tooltip-display-content {
display: none;
}
#AmazonPayButton:hover .apay-tooltip-display-content {
display: block;
}
#AmazonPayButton .apay-tooltip-display-content:after {
content: '';
position: absolute;
bottom: 100%;
left: 50%;
margin-left: -10px;
border-width: 9px;
border-style: solid;
border-color: transparent transparent rgb(47, 55, 61) transparent
}
</style>
</div>
<div id="walletWidgetDiv" style="height: 250px;width: 400px;"> </div>
<div id="consentWidgetDiv"> </div>
<div id="AmazonLogoutButton">
<a class="" href="https://secure.fredhutch.org/site/SPageServer?pagename=adf_agiv&experience=YEMatch23&s_src=december23&s_subsrc=aegeo23121&fh_element=nonhptoputilnav&creator=rkd&team=philanthropy" onclick="javascript:amazon.Login.MODLogoutClickHandler()">Log out of Amazon Payments</a>
</div>
<br>
<p>Amazon Payments is the secure payment for the Fred Hutchinson Cancer Research Center. <a href="https://payments.amazon.com/help/Amazon-Simple-Pay/Creating-Managing-Your-Account/Verifying-Your-Account" target="_blank">Learn more</a>
about Amazon Payments.</p>
<p>Amazon Payments protects your privacy and security.</p>
</div>
</fieldset>
</div>
</div>
</div>
</div>
<div id="billing_info_fields" class="cddevYourInformation rowflex columnflex-mobile donate-row">
<div class="cell collapse">
<fieldset>
<div class="rowflex columnflex-mobile section-padding-14px no-padding-top mobile-section-padding-14px">
<div class="cell small-twelve align-center">
<h4 class="section-header donate-xs-col-12 margin-bottom-none">Your Information</h4>
</div>
</div>
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px">
<div class="cell small-twelve align-center">
<label for="billing_name_first">First Name * <span id="required_field_ind_help">[* = required] </span></label>
<input type="text" name="billing.name.first" id="billing_name_first" required="" value="" aria-required="true">
</div>
</div>
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px">
<div class="cell small-twelve align-center">
<label for="billing_name_last">Last Name *</label>
<input type="text" name="billing.name.last" id="billing_name_last" required="" value="" aria-required="true">
</div>
</div>
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px">
<div class="cell small-twelve align-center">
<label for="billing_address_street1">Street Address Line 1 *</label>
<input type="text" name="billing.address.street1" id="billing_address_street1" required="" value="" placeholder="" class="pac-target-input" autocomplete="donor-street-address-field" aria-required="true">
</div>
</div>
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px">
<div class="cell small-twelve align-center">
<div class="show-street-2-fields hide">
<label for="billing_address_street2">Street Address Line 2</label>
<input type="text" name="billing.address.street2" id="billing_address_street2" value="">
</div>
<a class="show-street-2 display-block size-18px" href="#"><span class="show-street-2-span">+</span><span class="hide-street-2-span hide">-</span> Street Address Line 2 (optional)</a>
</div>
</div>
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px">
<div class="cell fourflex small-twelve align-center mobile-margin-bottom-20px">
<label for="billing_address_city">City *</label>
<input type="text" name="billing.address.city" id="billing_address_city" required="" value="" aria-required="true">
</div>
<div class="cell fourflex small-twelve align-center mobile-margin-bottom-20px">
<div class="donate-select">
<label for="billing_address_state">State/Province *</label>
<select name="billing.address.state" id="billing_address_state" required="" aria-required="true">
<option value="" selected="selected"></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">HA - 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">AE - 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="NF">NF - 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>
</div>
</div>
<div class="cell fourflex small-twelve align-center">
<label for="billing_address_zip">ZIP/Postal Code *</label>
<input type="text" name="billing.address.zip" id="billing_address_zip" required="" value="" aria-required="true">
</div>
</div>
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px">
<div class="cell small-twelve align-center">
<div class="donate-select">
<label for="billing_address_country">Country *</label>
<select name="billing.address.country" id="billing_address_country" required="" aria-required="true">
<option value="" selected="selected">Country *</option>
<option value="United States" selected="">United States</option>
<option value="United Kingdom">United Kingdom</option>
<option value="Afghanistan">Afghanistan</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="Bolivia">Bolivia</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="Congo, The Democratic Republic of The">Congo, The Democratic Republic of The</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="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</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="Fiji">Fiji</option>
<option value="Finland">Finland</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="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="Iran, Islamic Republic of">Iran, Islamic Republic of</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Korea, Democratic People's Republic of">Korea, Democratic People's Republic of</option>
<option value="Korea, Republic of">Korea, Republic of</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="Libyan Arab Jamahiriya">Libyan Arab Jamahiriya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macao">Macao</option>
<option value="Macedonia, The Former Yugoslav Republic of">Macedonia, The Former Yugoslav Republic of</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="Micronesia, Federated States of">Micronesia, Federated States of</option>
<option value="Moldova, Republic of">Moldova, Republic of</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</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="Netherlands Antilles">Netherlands Antilles</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="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</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 Helena">Saint Helena</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</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 and Montenegro">Serbia and Montenegro</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</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 Georgia and The South Sandwich Islands">South Georgia and The South Sandwich Islands</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="Tanzania, United Republic of">Tanzania, United Republic of</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 States">United States</option>
<option value="United States Minor Outlying Islands">United States Minor Outlying Islands</option>
<option value="Uruguay">Uruguay</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Venezuela">Venezuela</option>
<option value="Viet Nam">Viet Nam</option>
<option value="Virgin Islands, British">Virgin Islands, British</option>
<option value="Virgin Islands, U.S.">Virgin Islands, U.S.</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>
</div>
</div>
</div>
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px">
<div class="cell small-twelve align-center">
<label for="donor_phone">Phone Number</label>
<input type="text" name="donor.phone" id="donor_phone" value="">
</div>
</div>
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px">
<div class="cell small-twelve align-center">
<label for="donor_email">Email Address *</label>
<input type="text" name="donor.email" id="donor_email" required="" data-rule-email="true" value="" aria-required="true">
</div>
</div>
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px hidden">
<div class="cell small-twelve align-center">
<div class="selected">
<input type="checkbox" name="donor.email_opt_in" id="email-opt-in" value="true" checked="checked">
<label for="email-opt-in" class="checkbox-label">Yes, I would like to receive emails from Fred Hutchinson Cancer Research Center.</label>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<div class="rowflex columnflex-mobile donate-row section-padding-10px hidden">
<div class="cell">
<div class="spacer-line"></div>
</div>
</div>
<div class="cddevAnonymous rowflex columnflex-mobile donate-row section-padding-12px mobile-section-padding-12px ">
<div class="cell small-twelve align-center">
<fieldset>
<div class="rowflex columnflex-mobile">
<div class="cell small-twelve align-center collapse">
<input type="checkbox" name="anonymous" id="anonymous_donation" value="false">
<label for="anonymous_donation" class="checkbox-label">Please make my donation anonymous</label>
</div>
</div>
</fieldset>
</div>
</div>
<div class="rowflex columnflex-mobile donate-row section-padding-12px mobile-section-padding-12px terms_group">
<div class="cell small-twelve align-center">
<fieldset>
<div class="rowflex columnflex-mobile">
<div class="cell small-twelve align-center collapse">
<input type="checkbox" name="accept.terms" id="accept_terms" autocomplete="off" tabindex="-1">
<label for="accept_terms" class="checkbox-label">I accept the terms</label>
</div>
</div>
<div class="rowflex columnflex-mobile section-padding-12px mobile-section-padding-12px">
<div class="cell small-twelve align-center">
<label for="terms_inits">Terms Inits</label>
<input type="text" name="terms.inits" id="terms_inits" autocomplete="off" tabindex="-1">
</div>
</div>
</fieldset>
</div>
</div>
<div class="cddevJointRow rowflex columnflex-mobile donate-row ">
<div class="cell">
<fieldset>
<div class="rowflex columnflex-mobile">
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DOUBLE YOUR LIFESAVING IMPACT Your support will help our scientists deliver better treatments and cures that people facing cancer need desperately. Give now to make twice the impact. ERROR: YOUR DONATION FAILED TO PROCESS. PLEASE VERIFY YOUR PAYMENT INFORMATION AND TRY AGAIN. 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