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Submitted URL: https://steptemberparticipantsau.cmail20.com/t/j-l-vikyhil-dtdthkujz-y/
Effective URL: https://www.steptember.org.au/fundraisers/ShivaNithiaseelan
Submission: On September 23 via manual from AU — Scanned from AU
Effective URL: https://www.steptember.org.au/fundraisers/ShivaNithiaseelan
Submission: On September 23 via manual from AU — Scanned from AU
Form analysis
1 forms found in the DOMPOST https://www.steptember.org.au/sponsor/fundraiser/ShivaNithiaseelan/au
<form method="post" class="form-horizontal funraisin-form " id="ProfileDonationForm" action="https://www.steptember.org.au/sponsor/fundraiser/ShivaNithiaseelan/au" novalidate="novalidate">
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<div class="sidebar-form-panel text-center active" id="chooseamount">
<h4>
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<div class="donationHandlers minimal">
<div class="copy-text text-center"></div>
<div class="radio col-xs-3" data-rel="24" data-image="https://d1ycj7j4cqq4r8.cloudfront.net/1epg79x8ys6cc.jpg">
<div class="arrow-top border-primary"></div>
<a class="radio-text">
<span class="radio-wrap">
<span class="radio-copy hidden">Will support research to detect and treat CP as early as possible to maximise the benefit of treatments.</span>
<span class="radio-amount"><span>$24</span></span>
</span>
</a>
</div>
<div class="radio col-xs-3" data-rel="72" data-image="https://d1ycj7j4cqq4r8.cloudfront.net/2604wph5ar.jpg">
<div class="arrow-top border-primary"></div>
<a class="radio-text">
<span class="radio-wrap">
<span class="radio-copy hidden">Will support research into the causes and incidence of cerebral palsy to further prevention and treatment.</span>
<span class="radio-amount"><span>$72</span></span>
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<div class="radio col-xs-3" data-rel="105" data-image="https://d1ycj7j4cqq4r8.cloudfront.net/3414ly6k8yioog.jpg">
<div class="arrow-top border-primary"></div>
<a class="radio-text">
<span class="radio-wrap">
<span class="radio-copy hidden">Will support research into the use of technology to increase mobility, communication and independence for people living with cerebral palsy.</span>
<span class="radio-amount"><span>$105</span></span>
</span>
</a>
</div>
<div class="radio col-xs-3" data-rel="222" data-image="https://d1ycj7j4cqq4r8.cloudfront.net/ix0a7u9ldq1n.jpg">
<div class="arrow-top border-primary"></div>
<a class="radio-text">
<span class="radio-wrap">
<span class="radio-copy hidden">Will help researchers investigate potential treatments that use the body’s own regenerative capabilities.</span>
<span class="radio-amount"><span>$222</span></span>
</span>
</a>
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<span class="input-group-addon bg-primary">$</span>
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<label class="col-sm-12">Organisation Name *</label>
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<div class="col-md-6 Mandatory">
<div class="form-group">
<label class="col-sm-12" for="d_fname">First Name*</label>
<div class="col-sm-12">
<input type="text" class="form-control" name="d_fname" id="d_fname" value="" autocomplete="given-name">
</div>
</div>
</div>
<div class="col-md-6 Mandatory">
<div class="form-group">
<label class="col-sm-12" for="d_lname">Last Name*</label>
<div class="col-sm-12">
<input type="text" class="form-control" name="d_lname" id="d_lname" value="" autocomplete="family-name">
</div>
</div>
</div>
<div class="col-md-12 Mandatory">
<div class="form-group">
<label class="col-sm-12" for="d_email">Email Address*</label>
<div class="col-sm-12">
<input type="text" class="form-control" name="d_email" id="d_email" value="" autocomplete="email">
</div>
</div>
</div>
<input type="hidden" name="d_optin_text" value="I'm happy to hear more from the STEPtember team">
<div class="col-sm-12">
<div class="col-xs-12 pl0 pr0" style="font-size:86%;">
<div class="text-center toggle-switch right col-xs-4 pl0 pr0">
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<input type="radio" name="d_optin" value="Y"> Yes </label>
<label class="col-xs-6 toggle-btn d_optin" data-rel="N" onclick="$(this).parent().parent().find('label').removeClass('bg-primary border-primary');$(this).addClass('bg-primary border-primary');">
<input type="radio" name="d_optin" value="N"> No </label>
</div> I'm happy to hear more from the STEPtember team
</div>
</div>
<div class="clear"></div>
<div class="height-20"></div>
<div class="col-md-12">
<div class="height-10"></div>
<div class="text-center toggle-switch form-group">
<div class="col-xs-12">
<label class="bg-primary border-primary col-xs-6 toggle-btn" onclick="$('.d_comment').slideDown(300);$(this).parent().parent().find('label').removeClass('bg-primary border-primary');$(this).addClass('bg-primary border-primary');">
<input type="radio" name="d_leave_message" value="Y" checked="checked"> Leave a message </label>
<label class="col-xs-6 toggle-btn" onclick="$('.d_comment').slideUp(300);$(this).parent().parent().find('label').removeClass('bg-primary border-primary');$(this).addClass('bg-primary border-primary');">
<input type="radio" name="d_leave_message" value="N"> No Message </label>
</div>
</div>
<div class="height-20"></div>
<div class="form-group d_comment">
<label class="col-sm-12" for="d_comments">Message to Shiva Nithiaseelan (Optional)</label>
<div class="col-sm-12">
<textarea class="form-control" name="d_comments" id="d_comments" rows="4" cols="30"></textarea>
</div>
</div>
<div class="form-group d_comment">
<label class="col-sm-12" for="d_display_name">Name to appear on page</label>
<div class="col-sm-12">
<input class="form-control" type="text" name="d_display_name" id="d_display_name" autocomplete="name">
</div>
</div>
<div class="form-group">
<div class="col-sm-12">
<input type="checkbox" name="d_anonymous" value="Y" aria-label="I'd like to remain anonymous to the fundraiser"> <span style="font-size:86%;">I'd like to remain anonymous to the fundraiser</span>
</div>
</div>
<div class="height-20"></div>
<div class="form-group text-center">
<div class="col-sm-3"></div>
<div class="col-sm-6">
<a href="javascript:;" class="btn btn-tertiary btn-next btn-block" rel="paymentdetails" id="personaldetailsbutton">Next</a>
</div>
</div>
</div>
</div>
<div class="sidebar-form-panel col-sm-12" id="paymentdetails">
<p id="error" class="text-center error" style="display:none">
<b></b>
</p>
<div class="text-center toggle-switch form-group">
<div class="col-xs-12">
<label class="bg-primary border-primary col-xs-4 toggle-btn"
onclick="$('.creditcard').removeClass('hidden');$('.eft').addClass('hidden');$('.creditcard').visibleIn();$(this).parent().parent().find('label').removeClass('bg-primary border-primary');$(this).addClass('bg-primary border-primary');">
<input type="radio" name="payment_method" value="credit card" checked="checked"> Credit Card </label>
<label class="col-xs-4 toggle-btn"
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<input type="radio" name="payment_method" value="paypal"> <i class="fa fa-paypal" aria-hidden="true"></i> PayPal </label>
</div>
</div>
<div class="row eft hidden">
<div class="form-group">
<div class="col-sm-12 pt20 pb20"> If you wish to pay via Electronic Funds Transfer, please define a reference below to be used during the funds' transfer. Keep the value entered to a combination of numbers and letters. Upon submission, you
will receive an email with payment instructions which will include the value to be transferred, our bank details, and your reference number for payment. </div>
</div>
<div class="form-group">
<label class="col-sm-12">Your Reference</label>
<div class="col-sm-12">
<input class="form-control" type="text" name="eft_reference" id="eft_reference">
</div>
</div>
</div>
<div class="row creditcard">
<div class="form-group">
<label class="col-sm-12" for="card_name">Name on Card</label>
<div class="col-sm-12">
<input class="form-control" type="text" name="card_name" id="card_name" data-stripe="name" autocomplete="cc-name" x-autocompletetype="cc-name">
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<div class="row creditcard">
<div class="form-group">
<label class="col-sm-12" for="card_number">Card Number</label>
<div class="col-sm-12">
<input class="form-control" type="text" id="card_number" name="card_number" data-eway-encrypt-name="EWAY_CARDNUMBER" data-braintree-name="number" data-stripe="number" autocomplete="cc-number" x-autocompletetype="cc-number">
</div>
</div>
</div>
<div class="row creditcard">
<div class="form-group">
<label class="col-sm-12">Card Expiry</label>
<div class="col-xs-6">
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<div class="col-xs-6">
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</div>
</div>
</div>
<div class="row">
<div class="form-group">
<label class="col-sm-8 creditcard" for="card_cvv">CVV</label>
<label class="col-xs-4">Donation</label>
<div class="clear"></div>
<div class="col-xs-4 creditcard">
<input class="form-control" type="text" id="card_cvv" name="card_cvv" value="" maxlength="4" data-eway-encrypt-name="EWAY_CARDCVN" data-braintree-name="cvv" data-stripe="cvc" autocomplete="off">
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<div class="col-xs-4 creditcard">
<img src="/funraisin.4.1/images/cvv.png" style="width:55px;margin-top:-10px;">
</div>
<div class="col-sm-4">
<span class="currency">$</span><span class="amountdonating"></span>
</div>
</div>
</div>
<div class="row">
<div class="form-group">
<div class="col-sm-12" style="font-size: 16px; line-height: 24px;">
<input type="checkbox" name="d_optin_fees" id="d_optin_fees" value="Y" checked="checked"> I'd like to add 3.5% to help cover transaction fees so that more of my donation goes to life-changing cerebral palsy research. <span
id="amountfees"></span>
</div>
</div>
</div>
<div class="form-group text-center">
<button type="submit" class="btn btn-tertiary"><span>Donate now</span></button>
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</form>
Text Content
* Home * * The Challenge * The Cause * Organisations+ * Partners * Organisations * Get Inspired+ * Meet our trainers * Resources+ * Hints & Tips * Resources * App * Shop * Leaderboards * Search * FAQs * Donate * Register Interest * Register Login * * The Challenge * The Cause * Organisations * [Mega Nav] Partners See the organisations who have stepped up by partnering with STEPtember, or dollar matching their staff fundraising. Organisations Information about how organisations can participate by stepping and fundraising. * Be Inspired * Leaderboards * Registration * Register * Register Interest * Register * Donate * The Challenge * The Cause * Organisations * [MEGA NAV IN USE] Partners See the organisations who have stepped up by partnering with STEPtember, or dollar matching their staff fundraising. Organisations Information about how organisations can participate by stepping and fundraising. * Be Inspired * Leaderboards * Resources * [MEGA NAV IN USE] Hints & Tips Resources App * Shop * Login * Search * Faqs Login SHIVA NITHIASEELAN I STEP for cerebral palsy My Page My Team Page My Organisation Page PLEASE HELP ME REACH MY GOAL RAISED $0 MY GOAL $100 * $ * * SELECT AMOUNT TO DONATE Will support research to detect and treat CP as early as possible to maximise the benefit of treatments. $24 Will support research into the causes and incidence of cerebral palsy to further prevention and treatment. $72 Will support research into the use of technology to increase mobility, communication and independence for people living with cerebral palsy. $105 Will help researchers investigate potential treatments that use the body’s own regenerative capabilities. $222 $ Donate Personal Donation Company Donation Organisation Name * First Name* Last Name* Email Address* Yes No I'm happy to hear more from the STEPtember team Leave a message No Message Message to Shiva Nithiaseelan (Optional) Name to appear on page I'd like to remain anonymous to the fundraiser Next Credit Card PayPal If you wish to pay via Electronic Funds Transfer, please define a reference below to be used during the funds' transfer. Keep the value entered to a combination of numbers and letters. Upon submission, you will receive an email with payment instructions which will include the value to be transferred, our bank details, and your reference number for payment. Your Reference Name on Card Card Number Card Expiry CVV Donation $ I'd like to add 3.5% to help cover transaction fees so that more of my donation goes to life-changing cerebral palsy research. Donate now MY ACTIVITY TRACKING 107,310 Steps MY TARGET 300000 STEPS 09-0109-0209-0309-0409-0509-0909-1009-1109-1209-13010000200003000040000500006000070000800009000010000011000000.10.20.30.40.50.60.70.80.9109-0109-0209-0309-0409-0509-0909-1009-1109-1209-13 FOR PEOPLE LIVING WITH CEREBRAL PALSY. Taking 10,000 steps a day is one heck of a challenge! But every step will be made easier knowing it's all for a very worthy cause. Every dollar I raise will provide vital equipment, therapy and services to children and adults living with cerebral palsy as well as further research and innovative technology. Please help me support this great cause! OUR TEAM MEMBERS THIEN NGUYEN (C) Raised so far $51.75 EMMA HEWETT SHIVA NITHIASEELAN SANDI DUFFY Raised so far $50.00 * THE CAUSE * ORGANISATIONS * Partners * Organisations * BE INSPIRED * Leaderboards * FAQs Contact Us Privacy Statement Register Donate CONNECT WITH US © Cerebral Palsy Alliance | Terms and Conditions | Privacy Policy | Accessibility Cerebral Palsy Alliance (ACN 000 062 288), previously incorporated as “The Spastic Centre of New South Wales”, is a public benevolent institution incorporated as a company limited by guarantee. STEPtember and the STEPtember logo are trademarks of Cerebral Palsy Alliance. Cerebral Palsy Alliance, as a Charity, is Tax exempt and a registered Deductible Gift Recipient. All donations to Cerebral Palsy Alliance over $2.00 are tax deductible. --------------------------------------------------------------------------------