tidepool.salsalabs.org
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35.169.32.116
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Submitted URL: https://email.tidepool.org/MjQ4LUlTWi01MzYAAAGJRsMQWinPyJmeaKppkqViIQcjYM8oJbjE0XE_F8tOWqFQT5Ln4XtOMCHMJ3pZptvGGL34nZE=
Effective URL: https://tidepool.salsalabs.org/tidepool-donate/index.html?mkt_tok=MjQ4LUlTWi01MzYAAAGJRsMQWoFLMB4iLssn0Kpv7h1pCUbgZh9e-71IuLNlb...
Submission: On January 13 via manual from US — Scanned from DE
Effective URL: https://tidepool.salsalabs.org/tidepool-donate/index.html?mkt_tok=MjQ4LUlTWi01MzYAAAGJRsMQWoFLMB4iLssn0Kpv7h1pCUbgZh9e-71IuLNlb...
Submission: On January 13 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
<form class="sli-form fv-form fv-form-salsa" data-fv-framework="salsa" novalidate="novalidate" data-ignite-form-id="16aebf44-d22f-4876-88c5-3a25c6c03afb" id="id_4d6ecd37-56c3-41bc-bb4b-6b7b2cd9f319_form">
<div class="sli-row" id="id_d5161527-1676-44c2-8ca5-3b7f0ee795fb">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="elementStep" id="id_ebad4ff3-c3e5-42a0-bc25-ded1f5bea712" data-ignite-step-id="1">
<div class="sli-row" id="id_7d850530-33a8-4128-9e24-07e84fe9d15e">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_22ecf250-e6e6-48d4-8aa6-583551eb5fe3">
<div class="sli-step-navigation-wrapper sli-element" id="id_42c1e527-2e62-469f-b752-21148816c193">
<div class="sli-step-navigation-steps sli-flex-container">
<div class="sli-step-navigation-step sli-flex-item sli-vertical-align-top sli-selected" data-ignite-for-step-id="1" tabindex="0"> <a class="sli-step-marker">1</a>
<div class="sli-step-label"> <span class="sli-step-check">✓</span>Amount </div>
</div>
<div class="sli-step-navigation-step sli-flex-item sli-vertical-align-top" data-ignite-for-step-id="2" tabindex="0"> <a class="sli-step-marker">2</a>
<div class="sli-step-label"> <span class="sli-step-check">✓</span>Your Info </div>
</div>
<div class="sli-step-navigation-step sli-flex-item sli-vertical-align-top" data-ignite-for-step-id="3" tabindex="0"> <a class="sli-step-marker">3</a>
<div class="sli-step-label"> <span class="sli-step-check">✓</span>Payment </div>
</div>
<div class="sli-progress-line"></div>
</div>
</div>
<div class="sli-selectRecurring sli-element " id="id_cd9b8f4f-e984-44e2-b68a-9a4aba8924eb_bnDJyiBgdv" data-ignite-field-id="MakeRecurring"> <label class="sli-label"
for="id_cd9b8f4f-e984-44e2-b68a-9a4aba8924eb_bnDJyiBgdv_makeRecurring_input"><input class="sli-input" id="id_cd9b8f4f-e984-44e2-b68a-9a4aba8924eb_bnDJyiBgdv_makeRecurring_input" type="checkbox" name="makeRecurring" value="true"
style="margin-right: 5px;" salsa-reference-name="makerecurringcb">Make this donation recurring (select your recurring donation amount below)</label> </div>
</div>
</div>
<div class="sli-row" id="id_e928d5e6-e2f3-4d2c-91ce-258f359c2660">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_0f004903-e8e9-445e-a365-8e1ee93e082a">
<div class="sli-donation-amountblock sli-element sli-align-center-for-small sli-text-center-for-small" id="id_4d924abb-9c67-4750-aed6-490434f2adea" data-ignite-enable-onetime="true" data-ignite-enable-recurring-amounts="true"
data-ignite-field-id="DonationAmount">
<div class="sli-donationAmounts">
<div class="sli-oneTimeDonation" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_oneTime" data-ignite-onetime-amount="data-ignite-onetime-amount">
<ul class="sli-oneTimeDonationAmounts sli-style-button" style="justify-content: center;">
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_25" type="radio" data-ignite-amount="25.00" checked="checked" data-fv-onetimeamount="true"
data-sli-widget="xxxWidgetxxx" data-fv-row=".sli-oneTimeDonation" data-fv-err-container=".sli-oneTimeDonationError" data-fv-onetimeamount-message="Please select a donation amount, or enter your own amount"><label
class="sli-oneTimeAmountLabel sli-amount-label sli-small sli-flat" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_25_label" for="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_25">$25</label>
</li>
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_50" type="radio" data-ignite-amount="50.00"><label
class="sli-oneTimeAmountLabel sli-amount-label sli-small sli-flat" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_50_label" for="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_50">$50</label>
</li>
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_100" type="radio" data-ignite-amount="100.00"><label
class="sli-oneTimeAmountLabel sli-amount-label sli-small sli-flat" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_100_label"
for="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_100">$100</label></li>
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_250" type="radio" data-ignite-amount="250.00"><label
class="sli-oneTimeAmountLabel sli-amount-label sli-small sli-flat" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_250_label"
for="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_250">$250</label></li>
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_500" type="radio" data-ignite-amount="500.00"><label
class="sli-oneTimeAmountLabel sli-amount-label sli-small sli-flat" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_500_label"
for="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_500">$500</label></li>
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_1000" type="radio" data-ignite-amount="1000.00"><label
class="sli-oneTimeAmountLabel sli-amount-label sli-small sli-flat" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_1000_label"
for="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_1000">$1,000</label></li>
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_2500" type="radio" data-ignite-amount="2500.00"><label
class="sli-oneTimeAmountLabel sli-amount-label sli-small sli-flat" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_2500_label"
for="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_amt_2500">$2,500</label></li>
<li id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_custom" style=" display: block;"><input class="sli-oneTimeAmountRadio sli-oneTimeCustomAmount" name="donationAmtToggleOther"
id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_custom_radio" type="radio" data-ignite-custom-onetime="data-ignite-custom-onetime" aria-label="custom one-time donation amount">
<div class="sli-input-group"> <label class="sli-oneTimeAmountLabel sli-amount-label sli-customAmount sli-input-group-label sli-small sli-flat" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_custom_label"
for="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_custom">$</label> <input class="sli-oneTimeAmountInput sli-customAmount sli-input sli-input-group-field sli-small" size="5"
id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_onetime_custom" type="text" placeholder="Other" name="customOneTime" data-ignite-custom-onetime-input="donationAmtToggle" data-fv-row=".sli-oneTimeDonation"
data-fv-err-container=".sli-oneTimeDonationError" data-fv-numeric="true" data-fv-numeric-message="Please enter a dollar amount" data-fv-notempty="true" data-fv-notempty-message="An amount is required"
data-fv-greaterthan="true" data-fv-greaterthan-inclusive="false" data-fv-greaterthan-value="0.0" data-fv-greaterthan-message="Please enter a positive amount"> </div>
</li>
</ul>
<div class="sli-oneTimeDonationError"></div>
</div>
<div class="sli-recurringDonation" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurring" data-ignite-recurring-amount="data-ignite-recurring-amount" style="display:none;">
<p data-ignite-recurrence-frequency="Monthly" class=" sli-recurringFrequency" style="margin: 0;">Donation will repeat monthly.</p>
<ul class="sli-recurringDonationAmounts sli-style-button" style="justify-content: center;">
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_10" type="radio" data-ignite-amount="10.00" data-fv-recurringamount="true"
data-sli-widget="xxxWidgetxxx" data-fv-row=".sli-recurringDonation" data-fv-err-container=".sli-recurringDonationError" data-fv-recurringamount-message="Please select a donation amount, or enter your own amount"><label
class="sli-recurringAmountLabel sli-amount-label sli-small sli-flat" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_10_label"
for="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_10">$10</label></li>
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_25" type="radio" data-ignite-amount="25.00" checked="checked"><label
class="sli-recurringAmountLabel sli-amount-label sli-small sli-flat" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_25_label"
for="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_25">$25</label></li>
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_50" type="radio" data-ignite-amount="50.00"><label
class="sli-recurringAmountLabel sli-amount-label sli-small sli-flat" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_50_label"
for="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_50">$50</label></li>
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_75" type="radio" data-ignite-amount="75.00"><label
class="sli-recurringAmountLabel sli-amount-label sli-small sli-flat" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_75_label"
for="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_75">$75</label></li>
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_100" type="radio" data-ignite-amount="100.00"><label
class="sli-recurringAmountLabel sli-amount-label sli-small sli-flat" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_100_label"
for="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_100">$100</label></li>
<li id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_custom" style=" display: block;"><input class="sli-recurringAmountRadio sli-recurringCustomAmount" name="donationAmtToggle2Other"
id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_custom_radio" type="radio" aria-label="recurring donation custom amount">
<div class="sli-input-group"> <label class="sli-recurringAmountLabel sli-amount-label sli-customAmount sli-input-group-label sli-small sli-flat" id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_custom_label"
for="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_custom">$</label> <input class="sli-recurringAmountInput sli-customAmount sli-input sli-input-group-field sli-small" size="5"
id="id_4d924abb-9c67-4750-aed6-490434f2adea_CpewkWZRpI_recurringAmt_custom" type="text" placeholder="Other" name="customRecurringAmount" data-fv-row=".sli-recurringDonation" data-fv-err-container=".sli-recurringDonationError"
data-fv-numeric="true" data-fv-numeric-message="Please enter a dollar amount" data-fv-notempty="true" data-fv-notempty-message="An amount is required" data-fv-greaterthan="true" data-fv-greaterthan-inclusive="false"
data-fv-greaterthan-value="0.0" data-fv-greaterthan-message="Please enter a positive amount"> </div>
</li>
</ul>
<div class="sli-recurringDonationError"></div>
</div>
</div>
</div>
<div class="sli-donorPaysFees sli-element " id="id_710269f9-b1fb-431f-8dff-f9de26ed3cd7_yVYIUZUSVj" data-ignite-field-id="DonorPaysFees"> <label class="sli-label"
for="id_710269f9-b1fb-431f-8dff-f9de26ed3cd7_yVYIUZUSVj_donorPaysFees_input"><input class="sli-input" id="id_710269f9-b1fb-431f-8dff-f9de26ed3cd7_yVYIUZUSVj_donorPaysFees_input" type="checkbox" name="donorPaysFees" value="true"
checked="checked" style="margin-right: 5px;" salsa-reference-name="donorpaysfeescb">Increase donation amount to cover processing fees?</label> </div>
</div>
</div>
<div class="sli-row" id="id_7f8c9ff2-afe0-4efb-9c38-40c5ca8e2776">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_98ce4e61-c8ae-49d5-b4e4-e72ec2fda312">
<div class="sli-element sli-button-element" id="id_f652e0a0-e9aa-468a-9694-9c12aeb58ead">
<a class="sli-button sli-flat sli-expand" track="true" data-ignite-button-step="2" data-ignite-skip-validation="false" style="font-family:Roboto, sans-serif;background-color:rgb(98, 124, 255);border-radius:8px;border-style: solid;" tabindex="0">Next</a>
</div>
</div>
</div>
</div>
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="elementStep" id="id_7b628f1f-f9b2-4872-a54f-41ad1a9fccfb" style="display: none;" data-ignite-step-id="2">
<div class="sli-element sli-text" id="id_2134e197-0e5c-4085-bc7a-830af5506c94">
<div id="id_2134e197-0e5c-4085-bc7a-830af5506c94_inner">
<p> <span style="font-family:Roboto;"><span style="color:#4f6a92;"><span style="font-size:22px">Your Information</span></span></span> </p>
</div>
</div>
<div class="sli-row" id="id_c3e120ab-a958-442c-9dac-cc83654a70bb">
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_230baab7-65d8-4d11-bff9-ffa4f409cd18">
<div class="sli-field-person-firstname sli-form-field sli-element" data-ignite-field-id="5d5a2165-f19e-4371-851b-183a6b92402b" id="id_a3e8d4b7-9d70-4af2-a4fb-44c2258c84e5"> <label class="sli-required-true sli-label"
for="id_a3e8d4b7-9d70-4af2-a4fb-44c2258c84e5_input" id="id_a3e8d4b7-9d70-4af2-a4fb-44c2258c84e5_label">First Name*</label> <input class="sli-input sli-input-person-firstname" type="text"
data-ignite-field-id="5d5a2165-f19e-4371-851b-183a6b92402b" name="field-person-firstname" maxlength="36" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true"
data-fv-stringlengthmessage="Please limit your input to at most 36 characters." id="id_a3e8d4b7-9d70-4af2-a4fb-44c2258c84e5_input" salsa-reference-name="person-firstname"> </div>
</div>
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_34b45816-5c4f-4e7b-9478-c259bd4c57b1">
<div class="sli-field-person-lastname sli-form-field sli-element" data-ignite-field-id="8d21a878-287a-491f-a362-b8ee2aa71819" id="id_15ce84c2-597b-4b03-a7e3-3a9aed651e1f"> <label class="sli-required-true sli-label"
for="id_15ce84c2-597b-4b03-a7e3-3a9aed651e1f_input" id="id_15ce84c2-597b-4b03-a7e3-3a9aed651e1f_label">Last Name*</label> <input class="sli-input sli-input-person-lastname" type="text"
data-ignite-field-id="8d21a878-287a-491f-a362-b8ee2aa71819" name="field-person-lastname" maxlength="100" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true"
data-fv-stringlengthmessage="Please limit your input to at most 100 characters." id="id_15ce84c2-597b-4b03-a7e3-3a9aed651e1f_input" salsa-reference-name="person-lastname"> </div>
</div>
</div>
<div class="sli-row" id="id_6dcc3279-2097-4ff4-95d2-ade47b7c9802">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_d33e0b48-812f-4e64-aee4-b07afe4115c8">
<div class="sli-field-address-line1 sli-form-field sli-element" data-ignite-field-id="f775c79a-df41-43fb-96de-ee2360254689" id="id_20f2623c-b04f-4be6-ad4a-809ead537544"> <label class="sli-required-true sli-label"
for="id_20f2623c-b04f-4be6-ad4a-809ead537544_input" id="id_20f2623c-b04f-4be6-ad4a-809ead537544_label">Address, line 1*</label> <input class="sli-input sli-input-address-line1" type="text"
data-ignite-field-id="f775c79a-df41-43fb-96de-ee2360254689" name="field-address-line1" maxlength="128" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true"
data-fv-stringlengthmessage="Please limit your input to at most 128 characters." id="id_20f2623c-b04f-4be6-ad4a-809ead537544_input" salsa-reference-name="address-line1"> </div>
<div class="sli-field-address-country sli-form-field sli-element" data-ignite-field-id="f71a3605-b3a8-4650-af21-47387674a8eb" id="id_bd152cd6-69f2-4dcd-b450-f9fce4df3910"> <label class="sli-required-true sli-label"
for="id_bd152cd6-69f2-4dcd-b450-f9fce4df3910_input" id="id_bd152cd6-69f2-4dcd-b450-f9fce4df3910_label">Country*</label> <select class="sli-select-address-country sli-input" name="field-address-country"
data-ignite-field-id="f71a3605-b3a8-4650-af21-47387674a8eb" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" id="id_bd152cd6-69f2-4dcd-b450-f9fce4df3910_input"
salsa-reference-name="address-country">
<option value="AF">Afghanistan</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia, Plurinational State of</option>
<option value="BQ">Bonaire, Sint Eustatius and Saba</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BW">Botswana</option>
<option value="BV">Bouvet Island</option>
<option value="BR">Brazil</option>
<option value="IO">British Indian Ocean Territory</option>
<option value="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="CV">Cabo Verde</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo</option>
<option value="CD">Congo, The Democratic Republic of the</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CW">Curaçao</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czechia</option>
<option value="CI">Côte d'Ivoire</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="SZ">Eswatini</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (Malvinas)</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="GG">Guernsey</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard Island and McDonald Islands</option>
<option value="VA">Holy See (Vatican City State)</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IR">Iran, Islamic Republic of</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IM">Isle of Man</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JE">Jersey</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KP">Korea, Democratic People's Republic of</option>
<option value="KR">Korea, Republic of</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Lao People's Democratic Republic</option>
<option value="LV">Latvia</option>
<option value="LB">Lebanon</option>
<option value="LS">Lesotho</option>
<option value="LR">Liberia</option>
<option value="LY">Libya</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macao</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MH">Marshall Islands</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia, Federated States of</option>
<option value="MD">Moldova, Republic of</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="ME">Montenegro</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="MM">Myanmar</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="MK">North Macedonia</option>
<option value="MP">Northern Mariana Islands</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PS">Palestine, State of</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RO">Romania</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="RE">Réunion</option>
<option value="BL">Saint Barthélemy</option>
<option value="SH">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="MF">Saint Martin (French part)</option>
<option value="PM">Saint Pierre and Miquelon</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">Sao Tome and Principe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="RS">Serbia</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SX">Sint Maarten (Dutch part)</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="GS">South Georgia and the South Sandwich Islands</option>
<option value="SS">South Sudan</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard and Jan Mayen</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syrian Arab Republic</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania, United Republic of</option>
<option value="TH">Thailand</option>
<option value="TL">Timor-Leste</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US" selected="selected">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VE">Venezuela, Bolivarian Republic of</option>
<option value="VN">Viet Nam</option>
<option value="VG">Virgin Islands, British</option>
<option value="VI">Virgin Islands, U.S.</option>
<option value="WF">Wallis and Futuna</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
<option value="AX">Åland Islands</option>
</select> </div>
</div>
</div>
<div class="sli-row" id="id_565057ce-4f6c-43f6-85ed-b2b25b5a7e6b">
<div class="sli-large-4 sli-medium-4 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_1639ae1c-b533-4172-8108-a51db860ca03">
<div class="sli-field-address-city sli-form-field sli-element" data-ignite-field-id="a102d60f-f8ab-47eb-8ee0-864cfa1fc5b2" id="id_a664e10d-a1e4-44f7-8905-6d7adc1e57d3"> <label class="sli-required-true sli-label"
for="id_a664e10d-a1e4-44f7-8905-6d7adc1e57d3_input" id="id_a664e10d-a1e4-44f7-8905-6d7adc1e57d3_label">City*</label> <input class="sli-input sli-input-address-city" type="text" data-ignite-field-id="a102d60f-f8ab-47eb-8ee0-864cfa1fc5b2"
name="field-address-city" maxlength="64" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true"
data-fv-stringlengthmessage="Please limit your input to at most 64 characters." id="id_a664e10d-a1e4-44f7-8905-6d7adc1e57d3_input" salsa-reference-name="address-city"> </div>
</div>
<div class="sli-large-4 sli-medium-4 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_c78fdf7c-97fa-4e3e-8d9b-2c4880c29e7f">
<div class="sli-field-address-state sli-form-field sli-element" data-ignite-field-id="3f8b9098-ff2d-4384-bb95-425f113028c0" id="id_c0a72643-0373-4191-aa57-a3f9a5a0d3d6"> <label class="sli-required-true sli-label"
for="id_c0a72643-0373-4191-aa57-a3f9a5a0d3d6_input" id="id_c0a72643-0373-4191-aa57-a3f9a5a0d3d6_label">State*</label> <select class="sli-select-address-state sli-input" name="field-address-state"
data-ignite-field-id="3f8b9098-ff2d-4384-bb95-425f113028c0" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" id="id_c0a72643-0373-4191-aa57-a3f9a5a0d3d6_input"
salsa-reference-name="address-state">
<option value="" selected="selected"> Choose one...</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AS">American Samoa</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="AA">Armed Forces America</option>
<option value="AE">Armed Forces Europe</option>
<option value="AP">Armed Forces Pacific</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="GU">Guam</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="MP">Northern Mariana Islands</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VI">Virgin Islands</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select> </div>
</div>
<div class="sli-large-4 sli-medium-4 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_150c1081-4855-4cf0-bda3-f81dc526866b">
<div class="sli-field-address-zip sli-form-field sli-element" data-ignite-field-id="44e5ad15-1fdd-4ba8-bf38-f5cbaad023c2" id="id_fca539b0-d627-439f-827a-c28eed788218"> <label class="sli-required-true sli-label"
for="id_fca539b0-d627-439f-827a-c28eed788218_input" id="id_fca539b0-d627-439f-827a-c28eed788218_label">Zip Code*</label> <input class="sli-input sli-input-address-zip" type="text"
data-ignite-field-id="44e5ad15-1fdd-4ba8-bf38-f5cbaad023c2" name="field-address-zip" maxlength="20" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true"
data-fv-stringlengthmessage="Please limit your input to at most 20 characters." data-fv-zipcode="true" data-fv-zipcode-priority="1" data-fv-zipcode-country="US" data-fv-zipcode-message="This value is not valid as a %s postal code"
data-fv-regexp="true" data-fv-regexp-priority="2" data-fv-regexp-regexp="^(\d{5}|\d{5}-\d{4})?$" data-fv-regexp-message="Zip Code must be formatted as: "55555" or "55555-5555""
id="id_fca539b0-d627-439f-827a-c28eed788218_input" salsa-reference-name="address-zip"> </div>
</div>
</div>
<div class="sli-row" id="id_ae67bf28-f32c-4c20-bfc2-e3d60fe78537">
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_7428fc69-e7c4-4dd1-be76-033736db567d">
<div class="sli-field-contact-email sli-form-field sli-element" data-ignite-field-id="2851b463-606f-40c8-bb3d-d31f399e6896" id="id_d82ee44f-2f51-44ca-8f62-a5e5a6d41b3a"> <label class="sli-required-true sli-label"
for="id_d82ee44f-2f51-44ca-8f62-a5e5a6d41b3a_input" id="id_d82ee44f-2f51-44ca-8f62-a5e5a6d41b3a_label">Email Address*</label> <input class="sli-input sli-input-contact-email" type="email"
data-ignite-field-id="2851b463-606f-40c8-bb3d-d31f399e6896" name="field-contact-email" maxlength="128" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true"
data-fv-stringlengthmessage="Please limit your input to at most 128 characters." data-fv-regexp="true" data-fv-regexp-regexp="^[^@\s]+@([^@\s]+\.)+[^@\s]+$" data-fv-regexp-message="Please enter a valid email address"
id="id_d82ee44f-2f51-44ca-8f62-a5e5a6d41b3a_input" salsa-reference-name="contact-email"> </div>
</div>
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_14e59ccd-d45e-4777-94d4-9e7763b7a36d">
<div class="sli-field-person-home_phone sli-form-field sli-element" data-ignite-field-id="6e201e0b-8208-453f-b393-a5f0d9059726" id="id_e217d6ff-bd9e-41a7-ad70-2fc292f00a18"> <label class="sli-required-true sli-label"
for="id_e217d6ff-bd9e-41a7-ad70-2fc292f00a18_input" id="id_e217d6ff-bd9e-41a7-ad70-2fc292f00a18_label">Phone*</label> <input class="sli-input sli-input-person-home_phone" type="text"
data-ignite-field-id="6e201e0b-8208-453f-b393-a5f0d9059726" name="field-person-home_phone" placeholder="555-555-5555" maxlength="128" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value"
data-fv-stringlength="true" data-fv-stringlengthmessage="Please limit your input to at most 128 characters." id="id_e217d6ff-bd9e-41a7-ad70-2fc292f00a18_input" salsa-reference-name="person-home_phone"> </div>
</div>
</div>
<div class="sli-row" id="id_472262b8-325d-44c1-98e4-4c60e25b98fd">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_7e4febbf-4a25-491d-ba45-55399f30c53a">
<div id="id_eb8e84ae-455c-4b16-b678-2e6f5acabeee"> <label class="sli-label" for="dd-company-name-input">Let's see if your company will match your gift. Look up your company name here.</label>
<div id="dd-company-name-input"></div>
</div>
<div class="sli-donationsummary-dedication sli-columns sli-large-12 sli-select-radio sli-element " id="id_78e919e3-037a-4a75-a118-72c8f4a43046_dedication" salsa-reference-name="dedication_type">
<div> <label class="sli-label" for="id_78e919e3-037a-4a75-a118-72c8f4a43046_dedication" style="display: none;">Donation Notes</label>
<ul>
<li><input name="dedicationType" id="id_78e919e3-037a-4a75-a118-72c8f4a43046_NONE" value="NONE" type="radio" checked="checked">None</li>
<li><input name="dedicationType" id="id_78e919e3-037a-4a75-a118-72c8f4a43046_InHonorOf" value="InHonorOf" type="radio">In Honor Of</li>
<li><input name="dedicationType" id="id_78e919e3-037a-4a75-a118-72c8f4a43046_InMemoryOf" value="InMemoryOf" type="radio">In Memory Of</li>
</ul> <input class="sli-input" type="text" disabled="" name="dedication" data-fv-row=".sli-donationsummary-dedication" data-fv-nohtml="true" data-fv-nohtml-message="Your input is invalid" maxlength="250" data-fv-stringlength="true"
data-fv-stringlength-message="Please limit your input to less than 250 characters" data-fv-notempty="true" data-fv-notempty-message="Please provide a dedication" data-ignite-field-id="6a921941-0a96-474a-9c1d-f51aa791811b"
salsa-reference-name="donationsummary-dedication" placeholder="In honor of">
<div class="sli-dedicationError"></div>
<style ignite-allow-style="ignite-allow-style">
#id_78e919e3-037a-4a75-a118-72c8f4a43046_dedication li {
display: inline;
padding: 8px;
}
#id_78e919e3-037a-4a75-a118-72c8f4a43046_dedication input[type=radio] {
margin-right: 4px;
}
#id_78e919e3-037a-4a75-a118-72c8f4a43046_dedication ul {
margin: 4px;
padding: 0px;
}
@media screen and (max-width:640px) {
#id_78e919e3-037a-4a75-a118-72c8f4a43046_dedication li {
display: block;
padding: 2px 0 0 0;
}
}
</style>
</div>
</div>
<div class="sli-donationsummary-notify sli-element sli-form-field sli-columns sli-large-12 " id="id_a4703160-14ce-4f62-965e-c8285efe5c3f">
<div> <label class="sli-label" for="id_a4703160-14ce-4f62-965e-c8285efe5c3f_notify_input">Honoree contact (mailing or email address)</label> <input class="sli-input" id="id_a4703160-14ce-4f62-965e-c8285efe5c3f_notify_input" type="text"
name="field-donationsummary-notify" data-ignite-field-id="4abbf015-7829-4bda-a574-94ac97994229" data-fv-nohtml="true" data-fv-nohtml-message="Your input is invalid" maxlength="250" data-fv-stringlength="true"
data-fv-stringlength-message="Please limit your input to less than 250 characters" salsa-reference-name="donationsummary-notify"> </div>
</div>
<div class="sli-contact-types sli-element " id="id_14c73c51-5c50-4fd7-8ff6-0a06ebb6c821" data-ignite-field-id="ContactOptIn"> <label class="sli-label"><input class="sli-input sli-contact-type Email" type="checkbox"
id="id_14c73c51-5c50-4fd7-8ff6-0a06ebb6c821_contact_types_input" name="contactOptIn" value="accepted" style="margin-right: 5px;" data-ignite-contact-value="Email" salsa-reference-name="contactoptincb"> Yes, sign me up to receive
updates from Tidepool!</label>
<div class="sli-contact-type"></div>
</div>
<div class="sli-element sli-text" id="id_ce112601-c683-41a1-a4a0-cfb4af266ae7">
<div id="id_ce112601-c683-41a1-a4a0-cfb4af266ae7_inner">
<p style="text-align:center"> <span style="font-family:Roboto;"><span style="color:#808080"><em><span style="font-size:12px">Privacy is our priority. Tidepool will never share your email address or phone number with a 3rd
party.</span></em></span></span> </p>
</div>
</div>
</div>
</div>
<div class="sli-row" id="id_ad30ee8c-511e-4847-a3b3-523e52fa081b">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_18970c6e-8d5b-4139-9a64-15fb47210139">
<div class="sli-element sli-button-element" id="id_204bc87f-c854-48ff-9fd8-1b629f5261a2">
<a class="sli-button sli-floating sli-expand" track="true" data-ignite-button-step="3" data-ignite-skip-validation="false" style="font-family:Roboto, sans-serif;background-color:rgb(98, 124, 255);border-radius:8px;border-style: solid;" tabindex="0">Next</a>
</div>
<div class="sli-element sli-button-element" id="id_93ea8c5b-a378-4579-98dd-57f39eb4af6b">
<a class="sli-button sli-flat sli-small" track="true" data-ignite-button-step="1" data-ignite-skip-validation="true" style="font-family:Roboto, sans-serif;color:rgb(150,150,150);background-color:rgb(209,209,209);border-radius:8px;border-style: solid;" tabindex="0"><< Back</a>
</div>
</div>
</div>
</div>
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="elementStep" id="id_a9ee34ef-af97-4c25-9971-6dbd99e1e432" style="display: none;" data-ignite-step-id="3">
<div class="sli-row" id="id_296e0707-4720-46bc-8ec7-bb0e19d04090">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_d67d2143-bbca-4e06-a12e-43237a4905b8">
<div class="sli-element sli-text" id="id_64d6c0f1-a823-4f73-83bb-1ea78ee332f4">
<div id="id_64d6c0f1-a823-4f73-83bb-1ea78ee332f4_inner">
<p> <span style="font-size:22px"><strong>Payment Info</strong></span> </p>
</div>
</div>
<div class="sli-donation-paymentblock sli-element" id="id_09d6bf1d-9537-433a-a30a-68998db1a019">
<div class="sli-paymentType" id="id_09d6bf1d-9537-433a-a30a-68998db1a019_paymentType">
<div class="sli-ccType sli-label" for="payment_type"> Payment Type: </div>
<div style="display:inline-block;"> <input name="payment_type" type="radio" value="CREDIT_CARD" checked="checked" id="rumWCHCaTn"> <label class="sli-label" for="rumWCHCaTn">Credit Card</label> </div>
<div style="display:inline-block;"> <input name="payment_type" sli-payment-type="ACH" style="display:none;" type="radio" value="ACH" id="egzVHphfWj"> <label class="sli-label" style="display:none;" sli-payment-type="ACH"
for="egzVHphfWj">eCheck</label> </div>
<div style="display:inline-block;"> <input name="payment_type" sli-payment-type="PAYPAL" style="display:none;" type="radio" value="PAYPAL" id="QdCvDWddjb"> <label class="sli-label" style="display:none;" sli-payment-type="PAYPAL"
for="QdCvDWddjb">PayPal</label> </div>
</div>
<div id="id_09d6bf1d-9537-433a-a30a-68998db1a019_echeck_wepay" data-ignite-echeck-wepay="ignite-echeck-wepay"> <label class="sli-ccLabel sli-label" for="qTLAnwfliw">Bank Account*</label>
<div class="sli-row">
<div class="sli-columns sli-medium-4 sli-large-4 sli-end sli-form-field"></div> <input class="sli-ccInput sli-input" type="text" id="qTLAnwfliw" data-fv-field="wepay_bank" data-fv-notempty-message="Bank Account is required"
readonly="readonly" required="required" name="wepay_bank">
<div class="sli-columns sli-large-8 sli-medium-8"> <input class="sli-button" id="id_09d6bf1d-9537-433a-a30a-68998db1a019_bankSelect" type="button" value="Select a Bank Account" name="bank-popup"> <small
class="sli-field-error sli-wepay-error" style="display: none;"></small> </div>
</div>
</div>
<div id="id_09d6bf1d-9537-433a-a30a-68998db1a019_echeck" data-ignite-echeck="ignite-echeck">
<div class="sli-row">
<div class="sli-columns sli-medium-8 sli-large-8 sli-small-12 sli-end sli-form-field"> <label class="sli-ccLabel sli-label" for="TBPMcJergB">Name on Account*</label> <input class="sli-ccInput sli-input" type="text" name="holder_name"
id="TBPMcJergB" required="required" data-fv-notempty="true" data-fv-notemtpy-message="Please enter the holder name" pattern="^.+\s+.*$" data-fv-regexp-message="Holder name must have at least 2 parts"> </div>
</div>
<div class="sli-row">
<div class="sli-columns sli-large-8 sli-medium-8 sli-form-field"> <label class="sli-ccLabel sli-label" for="wObnJzeRgE">Bank Routing Number*</label> <input class="sli-ccInput sli-input" type="text" name="bank_routing" id="wObnJzeRgE"
required="required" maxlength="9" dava-fv-field="bank_routing" data-fv-notempty="true" data-fv-notemtpy-message="Bank Routing Number is required" data-fv-stringlength="true" data-fv-stringlength-min="9"
data-fv-stringlength-max="9" data-fv-stringlength-message="Bank Routing Number must be 9 characters long" data-fv-digits="true" data-fv-digits-message="Please enter only digits"> </div>
</div>
<div class="sli-row">
<div class="sli-columns sli-large-8 sli-medium-8 sli-form-field"> <label class="sli-ccLabel sli-label" for="wCPbUXAJNC">Bank Account Number*</label> <input class="sli-bankAccount sli-ccInput sli-input" type="text" name="bank_account"
id="wCPbUXAJNC" required="required" maxlength="17" dava-fv-field="bank_account" data-fv-notempty="true" data-fv-notemtpy-message="Bank Account Number is required" data-fv-stringlength="true" data-fv-stringlength-min="4"
data-fv-stringlength-max="17" data-fv-stringlength-message="Bank Account Number must be from 4 to 17 characters long" data-fv-digits="true" data-fv-digits-message="Please enter only digits"> </div>
</div>
</div>
<div id="id_09d6bf1d-9537-433a-a30a-68998db1a019_cc" data-ignite-cc="ignite-cc">
<ul class="sli-cards">
<li class="sli-visa" style="display:none;"></li>
<li class="sli-mastercard" style="display:none;"></li>
<li class="sli-discover" style="display:none;"></li>
<li class="sli-amex" style="display:none;"></li>
</ul>
<div class="sli-row">
<div class="sli-columns sli-large-8 sli-medium-8 sli-form-field"> <label class="sli-ccLabel sli-label" for="GunQflUPaz">Card Number*</label> <input class="sli-ccInput sli-input" name="card_number" id="GunQflUPaz" type="text"
required="required" data-fv-notempty-message="A credit card number is required" maxlength="16" autocomplete="off" data-fv-creditcard="true" data-fv-creditcard-message="Please enter a valid credit card number"> </div>
<div class="sli-columns sli-large-4 sli-medium-4 sli-end sli-form-field"> <label class="sli-ccExpCcvLabel sli-label" for="zrxaMwDMRf">Security Code*</label> <input class="sli-ccExpCcvInput sli-input" name="cvv" id="zrxaMwDMRf"
type="text" required="required" data-fv-notempty-message="CVV/CCV is required" maxlength="4" size="4" autocomplete="off" data-fv-cvv="true" data-fv-cvv_ccfield="card_number" data-dv-cvv-message="Your CVV is invalid"> </div>
</div>
<div class="sli-row">
<div class="sli-columns sli-large-6 sli-medium-6 sli-form-field"> <label class="sli-ccExpMonthLabel sli-label" for="dNVddiRcBS">Expiration Month*</label> <select class="sli-ccInput sli-input" name="expiry_month" id="dNVddiRcBS"
required="required" data-fv-notempty-message="Month is required" style="display: block;">
<option value="" selected="selected">MM</option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select> </div>
<div class="sli-columns sli-large-6 sli-medium-6 sli-end sli-form-field"> <label class="sli-ccExpMonthLabel sli-label" for="zvilPnvXmF">Expiration Year*</label> <select class="sli-ccInput sli-input" name="expiry_year" id="zvilPnvXmF"
required="required" data-fv-notempty-message="Year is required" style="display: block;">
<option value="" selected="selected">YYYY</option>
<option value="2021">21</option>
<option value="2022">22</option>
<option value="2023">23</option>
<option value="2024">24</option>
<option value="2025">25</option>
<option value="2026">26</option>
<option value="2027">27</option>
<option value="2028">28</option>
<option value="2029">29</option>
<option value="2030">30</option>
<option value="2031">31</option>
<option value="2032">32</option>
</select> </div>
</div>
<div class="sli-row">
<div class="sli-columns sli-large-12 sli-small-12 sli-end sli-form-field"> <label class="sli-ccNameLabel sli-label" for="dvUrHXJaSk">Name on Card*</label> <input class="sli-ccNameInput sli-input" name="name_on_card" id="dvUrHXJaSk"
type="text" autocomplete="off" required="required" data-fv-callback="true" data-fv-callback-callback="validateCCName"> </div>
</div>
</div>
</div>
</div>
</div>
<div class="sli-row" id="id_8b581867-be0d-4fff-beee-690d94dbf1e7">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_edd1664b-e73d-4125-b408-32735cdf5996">
<div class="sli-element sli-button-element" id="id_15b757c9-c65a-4d70-be67-95d0073942e6">
<a class="sli-button sli-flat sli-expand" track="true" data-ignite-submit-button="data-ignite-submit-button" style="font-family:Roboto, sans-serif;background-color:rgb(98, 124, 255);border-radius:8px;border-style: solid;" tabindex="0">Donate</a>
<div class="sli-processing" style="display:none;"></div>
</div>
<div class="sli-element sli-button-element" id="id_f2d0f228-0ef3-49c7-b4f1-ea90d9e3dae0">
<a class="sli-button sli-flat sli-small" track="true" data-ignite-button-step="2" data-ignite-skip-validation="true" style="font-family:Roboto, sans-serif;color:rgb(150,150,150);background-color:rgb(210,210,210);border-radius:8px;border-style: solid;" tabindex="0"><< Back</a>
</div>
</div>
</div>
</div>
</div>
</form>Text Content
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Look up your company name here. Donation Notes * None * In Honor Of * In Memory Of Honoree contact (mailing or email address) Yes, sign me up to receive updates from Tidepool! Privacy is our priority. Tidepool will never share your email address or phone number with a 3rd party. Next << Back Payment Info Payment Type: Credit Card eCheck PayPal Bank Account* Name on Account* Bank Routing Number* Bank Account Number* * * * * Card Number* Security Code* Expiration Month* MM010203040506070809101112 Expiration Year* YYYY212223242526272829303132 Name on Card* Donate << Back Thank you so much for your support. Tidepool Project is a fully-qualified 501(c)(3) nonprofit organization. FEIN 46-2302287. All contributions are tax deductible to the extent allowed by law. Terms of Use | Privacy Policy Contact Us info@tidepool.org Mail checks to: 555 Bryant St. #429, Palo Alto, CA 94301 Thank you so much for your support. You are helping make a real difference in the life of a person with diabetes, their care team, and the innovators who strive to make life-saving technology affordable and accessible to all. Tidepool Project is a fully-qualified 501(c)(3) nonprofit organization. FEIN 46-2302287. All contributions are tax-deductible to the extent allowed by law. Keep the momentum going by sharing with your friends on social media: Facebook Twitter LinkedIn