secure.info-komen.org
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Submitted URL: https://secure.info-komen.org/site/R?i=Skc1kpMa3YOWrIy3Lqr45UtrXFwXWUSEYQTHipitoj-Qrrp3s8_dvA
Effective URL: https://secure.info-komen.org/site/Donation2?df_id=23821&mfc_pref=T&23821.donation=form1&creative=fy22_evergreen_moments&utm_c...
Submission: On April 18 via api from US — Scanned from DE
Effective URL: https://secure.info-komen.org/site/Donation2?df_id=23821&mfc_pref=T&23821.donation=form1&creative=fy22_evergreen_moments&utm_c...
Submission: On April 18 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: process — POST https://secure.info-komen.org/site/Donation2
<form name="process" id="ProcessForm" action="https://secure.info-komen.org/site/Donation2" method="post" onsubmit="return checkDoubleClick();">
<div class="donation-form-container responsive">
<script type="text/javascript">
<!--
function reloadPage() {
window.location.reload(true);
}
function testAjax() {
var xmlHttp = null;
// Opera 8.0+, Firefox, Chrome, Safari
try {
xmlHttp = new XMLHttpRequest();
} catch (e) {
// Internet Explorer Browsers
try {
xmlHttp = new ActiveXObject("Msxml2.XMLHTTP");
} catch (e) {
try {
xmlHttp = new ActiveXObject("Microsoft.XMLHTTP");
} catch (e) {
return false;
}
}
}
xmlHttp.open('POST', 'AjaxHelper;jsessionid=00000000.app30120b?NONCE_TOKEN=F93D371E279B7043A1C9C70E34F34022', true);
xmlHttp.send();
}
addOnLoadHandler(testAjax);
//
-->
</script>
<div class="donation-form-content">
<input type="hidden" name="user_donation_amt" id="user_donation_amt" value="">
<input type="hidden" name="company_min_matching_amt" id="company_min_matching_amt" value="">
<input type="hidden" name="currency_locale" id="currency_locale" value="en_US">
<div class="form-row">
<div class="html-caption-container">
<!-- CONFIGURATION FILE -->
<!--
-- minAmount: Sets the minimumn amount accepted to make a transaction, it must be greater than 5 because Luminate Online does not process donations lower than 5
-- kProfiles: Edit each profile with the values you want as default, enclosed in square brackets and separated by a comma
-- feeValue: Set the fee percentage, use anything from 0 to 100
-- defaultFee: Use true or false to preselect the "Cover fees" option in the donation form
-- eCards: Replace the thumbnails generated by Luminate Online with better resolution images. The images must be placed in the exact order Luminate renders the native eCard images.
-- monthlyRate: Sets the rate to calculate the monthly amounts based on the One Time amounts. ie: (100 x 0.25) = 25
-->
<!-- DO NOT REMOVE! -->
<!-- DO NOT EDIT THE VARIABLE NAMES! -->
<script>
var formConfig = {
minAmount: 5,
kProfiles: {
'kprofile1': [10, 20, 30, 40],
'kprofile2': [100, 200, 300, 400],
'kprofile3': [1000, 2000, 3000, 4000],
},
feeValue: 4,
defaultFee: true,
eCards: ['../images/content/pagebuilder/Ecard_2021_Congrats.jpg', '../images/content/pagebuilder/Ecard_2021_Anniversary.jpg', '../images/content/pagebuilder/Ecard_2021_Birthday.jpg',
'../images/content/pagebuilder/Ecard_Happy_Holidays.jpg', '../images/content/pagebuilder/Ecard_2021_Honor.jpg', '../images/content/pagebuilder/Ecard_2021_Thinking_of_You.jpg',
],
monthlyRate: 25,
allComms: true,
formIdentifier: '23821',
twthzip_on: true,
urlTWTH: 'https://5b845arnv6.execute-api.us-east-1.amazonaws.com/production/lookup-zipcode-twht',
//urlTWTH: 'https://google.com:81/',
firstPartSements: ['TWTH-', 'LWTH-'],
secondPartSements: ['MAC', 'OTH'],
twthSegmentsArrays: {
'TWTH-MAC': ['50', '100', '150', '250', '500'],
'TWTH-OTH': ['50', '75', '125', '250', '500'],
'LWTH-MAC': ['50', '75', '125', '250', '500'],
'LWTH-OTH': ['25', '55', '100', '250', '500'],
'TWTH-DEFAULT': ['25', '55', '100', '250', '500']
},
urlTATWTH: 'https://lookup.dmc.systems/lookup-ta-twth',
taarray_onoroff: true,
taSegmentsArrays: {
'TA_Segment_1': ['25', '50', '75'],
'TA_Segment_2': ['50', '75', '100'],
'TA_Segment_3': ['75', '100', '150'],
'TA_Segment_4': ['100', '150', '250'],
'TA_Segment_5': ['150', '250', '500'],
'TA_Segment_6': ['250', '500', '1000'],
'TA_Segment_Default': ['25', '50', '75']
}
}
</script>
</div>
</div>
<div id="level_standard_row">
<div class="don-standard-levels form-row">
<div class="levels-label">
</div>
<div id="level_standard_row" class="form-row form-donation-level">
<div class="form-content">
<span class="field-required"></span> <span class="aural-only">Field Is Required</span>
<span class="FormLabelText">Select Gift Amount:</span>
<div class="donation-level-general-ask">
</div>
<div class="donation-levels">
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded81134" value="81134" onclick="evalMatchingGift('$25.00');
updateDonorCoverAmount('$25.00');">
</div>
<label for="level_standardexpanded81134" onclick="">
<div class="donation-level-amount-container"> $25.00 </div>
<div class="donation-level-label-container"> 25 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_81134expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded81137" value="81137" onclick="evalMatchingGift('$55.00');
updateDonorCoverAmount('$55.00');">
</div>
<label for="level_standardexpanded81137" onclick="">
<div class="donation-level-amount-container"> $55.00 </div>
<div class="donation-level-label-container"> 55 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_81137expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded81136" value="81136" onclick="evalMatchingGift('$100.00');
updateDonorCoverAmount('$100.00');">
</div>
<label for="level_standardexpanded81136" onclick="">
<div class="donation-level-amount-container"> $100.00 </div>
<div class="donation-level-label-container"> 100 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_81136expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded81139" value="81139" onclick="evalMatchingGift('$250.00');
updateDonorCoverAmount('$250.00');">
</div>
<label for="level_standardexpanded81139" onclick="">
<div class="donation-level-amount-container"> $250.00 </div>
<div class="donation-level-label-container"> 250 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_81139expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded81138" value="81138" onclick="evalMatchingGift('$500.00');
updateDonorCoverAmount('$500.00');">
</div>
<label for="level_standardexpanded81138" onclick="">
<div class="donation-level-amount-container"> $500.00 </div>
<div class="donation-level-label-container"> 500 </div>
</label>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_81138expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded81135" value="81135" onclick="evalMatchingGift(document.getElementById('level_standardexpanded81135amount').value);
updateDonorCoverAmount(document.getElementById('level_standardexpanded81135amount').value);">
</div>
<label for="level_standardexpanded81135" onclick="">
<div class="donation-level-label-container"> Enter an Amount </div>
</label>
<div class="donation-level-user-entered">
<label for="level_standardexpanded81135amount"><span class="aural-only">Enter amount</span></label>
<input type="text" name="level_standardexpanded81135amount" id="level_standardexpanded81135amount" value="" size="12" maxlength="50"
onfocus="var el = document.getElementById ('level_standardexpanded81135');if (el) el.click(); fire_obs_comp_event('level_standardexpanded81135amount', this, event);evalMatchingGift(value); "
onchange="fire_obs_comp_event('level_standardexpanded81135amount', this, event);evalMatchingGift(value);" onkeyup="fire_obs_comp_event('level_standardexpanded81135amount', this, event);evalMatchingGift(value);"
onblur="fire_obs_comp_event('level_standardexpanded81135amount', this);updateDonorCoverAmount(value);">
</div>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_81135expandedsubmit" value="true">
</div>
</div>
</div>
</div>
<script type="text/javascript">
Y.use("jquery-ui", function(Y) {
jQuery(function() {
// subscribe observables
jQuery('div.donation-level-element-container').find('input[type="radio"]').each(function() {
var syncAction = function(obj) {
if (obj.is(':checked')) {
obj.closest('div.donation-level-container').addClass('selected');
} else {
obj.closest('div.donation-level-container').removeClass('selected');
};
return arguments.callee;
}(jQuery(this));
jQuery(this).click(function() {
jQuery('div.donation-level-container').removeClass('selected');
syncAction(jQuery(this));
});
});
});
});
</script><noscript> </noscript>
</div>
<div class="levels-gift-aid">
</div>
<input type="hidden" name="level_standardsubmit" id="level_standardsubmit" value="true">
<script type="text/javascript">
function updateDonorCoverAmount(gift) {
if (typeof updateAmount !== "undefined") {
updateAmount(gift);
}
};
function evalMatchingGift(gift) {}
</script><noscript> </noscript>
</div>
<div class="donation-level-container-generic-repeat form-input">
<div class="generic-repeat-label-checkbox-container">
<input type="checkbox" name="level_standardauto_repeatname" id="level_standardauto_repeatname" onclick="fire_obs_comp_event('level_standardauto_repeat', this);" onkeypress="fire_obs_comp_event('level_standardauto_repeat', this);">
<label for="level_standardauto_repeatname"> Yes, automatically repeat this gift every month. </label>
</div>
<input type="hidden" name="level_standardauto_repeatsubmit" id="level_standardauto_repeatsubmit" value="true">
</div>
<script type="text/javascript">
// subscribe listeners to make an ajax call to the server to calculate the total amount
Y.use('jquery-noconflict', function() {
var fetchAmountFunc = function() {
// find all the select, textarea, input, etc... and format them into key=val pairs.
var params = jQuery('#level_standard_row :input').serialize();
// parse the path and append the key/value pairs above to the url
var url = 'https://secure.info-komen.org/site/Donation2?idb=876618871&level_standardajaxfetch=true&df_id=23821&mfc_pref=T&23821.donation=form1&level_standardtotalcalculateBtn=true';
var index = url.indexOf("?");
var path = url.substring(0, index);
var args = url.substring(index + 1, url.length);
args += '&' + params;
var recurringGiftTermsContainer = jQuery('#recurring_gift_terms_acceptance_message_container');
if (recurringGiftTermsContainer && recurringGiftTermsContainer.length > 0) {
jQuery.ajax(path, {
data: args,
success: function(data) {
jQuery('#recurring_gift_terms_acceptance_message_container').trigger("recurringTermsChange");
}
});
}
};
jQuery('#level_standard_row :input[type=text]').blur(function() {
fetchAmountFunc();
});
jQuery('#level_standard_row input:checkbox, #level_standard_row input:radio').click(function() {
fetchAmountFunc();
});
jQuery('#level_standard_row select').change(function() {
fetchAmountFunc();
});
// call it on page load
fetchAmountFunc();
});
</script><noscript> </noscript>
</div>
<div class="form-row">
<div class="html-caption-container">
<!-- DO NOT MODIFY! -->
<!-- DO NOT REMOVE! -->
<!-- Donation Frequency Selectors -->
<div id="frequency-controls">
<div class="frequency-control">
<span id="monthly"> Monthly </span>
</div>
<div class="frequency-control selected">
<span id="one-time"> One-time </span>
</div>
</div>
</div>
</div>
<h2 class="section-header-container"> Donation Amount (USD) </h2>
<div class="form-row">
<div class="html-caption-container">
<!-- DO NOT MODIFY! -->
<!-- DO NOT REMOVE! -->
<!-- Gift Array Section -->
<div id="gift-array">
<div class="loading-gift-array" style="display: none;">
<div class="loading-animation">
<div></div>
</div>
</div>
<div id="monthly-buttons" style="display: none;">
<div class="gift-array-item" id="25" data-amount="25">$25</div>
<div class="gift-array-item" id="55" data-amount="55">$55</div>
<div class="gift-array-item" id="100" data-amount="100">$100</div>
<div class="gift-array-item" id="250" data-amount="250">$250</div>
<div class="gift-array-item" id="500" data-amount="500">$500</div>
<div id="other-amount-monthly" class="gift-array-item">OTHER</div>
</div>
<div id="one-time-buttons" style="display: flex;">
<div class="gift-array-item" id="25" data-amount="25">$25</div>
<div class="gift-array-item" id="55" data-amount="55">$55</div>
<div class="gift-array-item chosen-amount" id="100" data-amount="100">$100</div>
<div class="gift-array-item" id="250" data-amount="250">$250</div>
<div class="gift-array-item" id="500" data-amount="500">$500</div>
<div id="other-amount-one" class="gift-array-item">OTHER</div>
</div>
<div id="other-amount-container" class="row" style="display: none;">
<p id="dollar-icon">$</p>
<input type="text" name="other-amount-input" id="other-amount-input" onpaste="return false" autocomplete="off">
</div>
<div id="gift-array-warning" class="row" style="display:none;">
<span></span>
</div>
</div>
</div>
</div>
<div id="tribute_show_honor_fields_row" class="form-row form-checkbox">
<div class="form-content">
<input type="checkbox" name="tribute_show_honor_fieldsname" id="tribute_show_honor_fieldsname" onclick="fire_obs_comp_event('tribute_show_honor_fields', this);">
<label for="tribute_show_honor_fieldsname">Yes, this is an honor or memorial gift</label>
<input type="hidden" name="tribute_show_honor_fieldssubmit" id="tribute_show_honor_fieldssubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_show_honor_fields', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_show_honor_fields_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('tribute_show_honor_fieldsname')) {
document.getElementById('tribute_show_honor_fieldsname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('tribute_show_honor_fieldsname')) {
return document.getElementById('tribute_show_honor_fieldsname').checked;
}
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
<p id="tribute-caption"></p>
</div>
</div>
<div id="tribute-fields-wrapper">
<div id="tribute_type_row" class="form-row form-selectlist" style="display: none;">
<div class="form-content">
<span class="field-required"></span><label class="FormLabel" for="tribute_type">My gift is</label>
<select name="tribute_type" id="tribute_type" size="1">
<option></option>
<option value="tribute_type_value1">In Memory of</option>
<option value="tribute_type_value2">In Honor of</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('tribute_type', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_type_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="tribute_typesubmit_skip" id="tribute_typesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_type', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_type_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_type'));
function tribute_type_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('tribute_type', src);
}
}
var el = document.getElementById('tribute_type');
if (el) {
Utils.addEvent(el, 'change', tribute_type_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_honoree_last_name_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<span class="field-required"></span><label for="tribute_honoree_last_namename">Person's Name or Occasion</label><small id="name-ocassion-info">Maximum of 50 character with spaces (e.g. John Smith, Sue Smith's Birthday)</small>
<input type="text" name="tribute_honoree_last_namename" id="tribute_honoree_last_namename" value="" maxlength="50"><small id="name-ocassion-char-count">0/50 characters</small>
<input type="hidden" name="tribute_honoree_last_namesubmit_skip" id="tribute_honoree_last_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_honoree_last_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_honoree_last_name_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_honoree_last_name'));
</script><noscript> </noscript>
</div>
</div>
<h2 class="section-header-container"> Would you like to send a Tribute Card? </h2>
<p id="ecard-notice">We also offer e-cards to be delivered to the email address of your choice same day or scheduled for a future date for donations made via komen.org.</p>
<div class="custom-field-container form-row ">
<div class="form-content">
<fieldset id="tribute-options">
<div class="radio-button-container">
<input type="radio" name="send_tribute_radio" id="send_tribute_radio_No_Thanks" value="No_Thanks">
<div class="form-input-label-block">
<label for="send_tribute_radio_No_Thanks">No Thanks</label>
</div>
</div>
<div class="radio-button-container">
<input type="radio" name="send_tribute_radio" id="send_tribute_radio_Yes_eCard" value="Yes_eCard">
<div class="form-input-label-block">
<label for="send_tribute_radio_Yes_eCard">Yes eCard</label>
</div>
</div>
<div class="radio-button-container">
<input type="radio" name="send_tribute_radio" id="send_tribute_radio_Yes_Mail_Card" value="Yes_Mail_Card">
<div class="form-input-label-block">
<label for="send_tribute_radio_Yes_Mail_Card">Yes Mail Card</label>
</div>
</div>
</fieldset>
<input type="hidden" name="send_tributesubmit" id="send_tributesubmit" value="true">
</div>
</div>
</div>
<div id="ecard-fields-wrapper">
<div id="send_ecard_row" class="form-row form-checkbox">
<div class="form-content">
<span class="check-box-form-label-text">Yes, Send an eCard</span>
<input type="checkbox" name="send_ecardname" id="send_ecardname" onclick="fire_obs_comp_event('send_ecard', this);">
<label for="send_ecardname">Yes, I would like to send an eCard.</label>
<input type="hidden" name="send_ecardsubmit" id="send_ecardsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('send_ecard', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('send_ecard_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('send_ecardname')) {
document.getElementById('send_ecardname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('send_ecardname')) {
return document.getElementById('send_ecardname').checked;
}
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
</div>
</div>
<div id="ecard_send_date_row" class="form-row form-date">
<div class="form-content">
<label for="ecard_send_date_MONTH">
<span class="label-text">Select a send date for your eCard:</span><span class="aural-only">Select month of credit card</span>
</label>
<label for="ecard_send_date_YEAR"><span class="aural-only">Select Expiration Year</span></label>
<div class="date-input-container">
<select name="ecard_send_date_MONTH" id="ecard_send_date_MONTH" title="Month">
<option value="1">Jan</option>
<option value="2">Feb</option>
<option value="3">Mar</option>
<option value="4" selected="selected">Apr</option>
<option value="5">May</option>
<option value="6">Jun</option>
<option value="7">Jul</option>
<option value="8">Aug</option>
<option value="9">Sep</option>
<option value="10">Oct</option>
<option value="11">Nov</option>
<option value="12">Dec</option>
</select>
<select name="ecard_send_date_DAY" id="ecard_send_date_DAY" title="Day">
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18" selected="selected">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select>
<select name="ecard_send_date_YEAR" id="ecard_send_date_YEAR" title="Year">
<option value="2033">2033</option>
<option value="2032">2032</option>
<option value="2031">2031</option>
<option value="2030">2030</option>
<option value="2029">2029</option>
<option value="2028">2028</option>
<option value="2027">2027</option>
<option value="2026">2026</option>
<option value="2025">2025</option>
<option value="2024">2024</option>
<option value="2023" selected="selected">2023</option>
</select>
</div>
<input type="hidden" name="ecard_send_datesubmit" id="ecard_send_datesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('ecard_send_date', 'input');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('ecard_send_date_row', _display);
disable_submit_flag('ecard_send_datesubmit', _hidden);
}
comp.disable = function(_disabled) {
disable_element('ecard_send_date_MONTH', _disabled);
disable_element('ecard_send_date_DAY', _disabled);
disable_element('ecard_send_date_YEAR', _disabled);
disable_element('ecard_send_date_HOUR12', _disabled);
disable_element('ecard_send_date_HOUR24', _disabled); //For UK, 24 hour clock used
disable_element('ecard_send_date_MINUTE', _disabled);
disable_element('ecard_send_date_AMPM', _disabled);
}
</script><noscript> </noscript>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<!-- THIS PART IS NECESSARY TO GENERATE THE ECARD PREVIEW -->
<!-- DO NOT REMOVE -->
<div id="ecard-field-sender">
<div class="form-content">
<span class="field-required"></span>
<label for="ecard-field-sender-name">Who is sending the eCard? (Name or Email Address)</label>
<input type="text" id="ecard-field-sender-name">
</div>
</div>
</div>
</div>
<div id="ecard_recpients_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="ecard_recpientsname">Recipient email addresses:</label>
<textarea cols="60" rows="4" name="ecard_recpientsname" id="ecard_recpientsname"></textarea><small>Please separate additional emails with commas ","</small>
<input type="hidden" name="ecard_recpientssubmit" id="ecard_recpientssubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('ecard_recpients', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('ecard_recpients_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="select_grid_row" class="form-row form-text">
<div class="form-content">
<label for="select_gridname">Select an eCard:</label>
<input type="hidden" name="stationery_layout_chooser" id="stationery_layout_chooser" value="true">
<div class="layout-chooser-container clearfix">
<div class="layout-choice-thumbnail-container">
<label class="layout-choice-thumbnail-label" for="stationery_layout_id_18199">
<img src="../images/content/pagebuilder/Ecard_2021_Congrats.jpg" alt="Congratulations" border="0">
</label>
<input type="radio" name="stationery_layout_id" id="stationery_layout_id_18199" value="18199" checked="checked">
</div>
<div class="layout-choice-thumbnail-container">
<label class="layout-choice-thumbnail-label" for="stationery_layout_id_14034">
<img src="../images/content/pagebuilder/Ecard_2021_Anniversary.jpg" alt="Happy Anniversary" border="0">
</label>
<input type="radio" name="stationery_layout_id" id="stationery_layout_id_14034" value="14034">
</div>
<div class="layout-choice-thumbnail-container">
<label class="layout-choice-thumbnail-label" for="stationery_layout_id_18195">
<img src="../images/content/pagebuilder/Ecard_2021_Birthday.jpg" alt="Happy Birthday" border="0">
</label>
<input type="radio" name="stationery_layout_id" id="stationery_layout_id_18195" value="18195">
</div>
<div class="layout-choice-thumbnail-container">
<label class="layout-choice-thumbnail-label" for="stationery_layout_id_18198">
<img src="../images/content/pagebuilder/Ecard_Happy_Holidays.jpg" alt="Happy Holidays" border="0">
</label>
<input type="radio" name="stationery_layout_id" id="stationery_layout_id_18198" value="18198">
</div>
<div class="layout-choice-thumbnail-container">
<label class="layout-choice-thumbnail-label" for="stationery_layout_id_18147">
<img src="../images/content/pagebuilder/Ecard_2021_Honor.jpg" alt="In Honor" border="0">
</label>
<input type="radio" name="stationery_layout_id" id="stationery_layout_id_18147" value="18147">
</div>
<div class="layout-choice-thumbnail-container">
<label class="layout-choice-thumbnail-label" for="stationery_layout_id_14038">
<img src="../images/content/pagebuilder/Ecard_2021_Thinking_of_You.jpg" alt="Thinking of you" border="0">
</label>
<input type="radio" name="stationery_layout_id" id="stationery_layout_id_14038" value="14038">
</div>
</div>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('select_grid', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('select_grid_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script><noscript> </noscript>
<input type="hidden" name="select_gridsubmit" id="select_gridsubmit" value="true">
</div>
</div>
<div id="tribute_ecard_subject_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_ecard_subjectname">eCard Subject:</label>
<input type="text" name="tribute_ecard_subjectname" id="tribute_ecard_subjectname" value="" maxlength="50">
<input type="hidden" name="tribute_ecard_subjectsubmit" id="tribute_ecard_subjectsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_ecard_subject', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_ecard_subject_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_ecard_message_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="tribute_ecard_messagename">eCard Message: (Up to 247 characters)</label>
<textarea cols="60" rows="4" name="tribute_ecard_messagename" id="tribute_ecard_messagename" placeholder="Type your eCard message here..." maxlength="247"></textarea><small id="ecard-message-char-count">0/247 characters</small>
<input type="hidden" name="tribute_ecard_messagesubmit" id="tribute_ecard_messagesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_ecard_message', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_ecard_message_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="preview_button_row" class="form-row">
<label for="preview_buttonname"></label>
<div id="null_row" class="form-row form-button">
<div class="form-content">
<button class="step-button action-button" type="submit" name="nullbtn" id="nullbtn" value="eCard Preview" title="Reloads page. "> eCard Preview </button>
<input type="hidden" name="nullsubmit" id="nullsubmit" value="true">
</div>
</div>
<input type="hidden" name="preview_buttonsubmit" id="preview_buttonsubmit" value="true">
</div>
<div class="form-row">
<div class="html-caption-container">
<!-- REQUIRED CONTROL FOR THE ECARD OPTION -->
<!-- DO NOT REMOVE -->
<div id="preview-ecard-container">
<span id="preview-ecard-button"> eCard Preview </span>
</div>
</div>
</div>
<div id="e_card_copy_sender_row" class="form-row form-checkbox">
<div class="form-content">
<input type="checkbox" name="e_card_copy_sendername" id="e_card_copy_sendername" onclick="fire_obs_comp_event('e_card_copy_sender', this);">
<label for="e_card_copy_sendername">Yes, send me a copy of the eCard.</label>
<input type="hidden" name="e_card_copy_sendersubmit" id="e_card_copy_sendersubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('e_card_copy_sender', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('e_card_copy_sender_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('e_card_copy_sendername')) {
document.getElementById('e_card_copy_sendername').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('e_card_copy_sendername')) {
return document.getElementById('e_card_copy_sendername').checked;
}
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
</div>
</div>
</div>
<div id="mail-card-fields-wrapper">
<div class="custom-field-container form-row ">
<div class="form-content">
<div class="form-input-label-block">
<label for="mail_card_personal_message_yn_dropdown">Would you like to include a personal message to the Tribute recipient?</label>
</div>
<fieldset>
<input type="checkbox" name="mail_card_personal_message_yn_radio" id="mail_card_personal_message_yn_radio" value="true">
<label class="custom-element-checkbox-label" for="mail_card_personal_message_yn_radio">Yes</label>
</fieldset>
<input type="hidden" name="mail_card_personal_message_ynsubmit" id="mail_card_personal_message_ynsubmit" value="true">
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<!-- REQUIRED CONTROL FOR THE MAIL CARD OPTION -->
<!-- DO NOT REMOVE -->
<div id="personal-message-container" class="form-content"><textarea name="personal-message" id="mail-card-personal-mesage" cols="60" rows="4" maxlength="255" placeholder="Type your personal message here..."></textarea> <small
id="personal-message-char-count">0/255 characters</small></div>
</div>
</div>
<div class="custom-field-container form-row " id="hidden-personal-message">
<div class="form-content">
<div class="form-input-label-block">
<label for="mail_card_personal_message_txt_input">Mail Card Personal Message Txt</label>
</div>
<input type="text" name="mail_card_personal_message_txt_input" id="mail_card_personal_message_txt_input" value="" maxlength="255">
<input type="hidden" name="mail_card_personal_message_txtsubmit" id="mail_card_personal_message_txtsubmit" value="true">
</div>
</div>
<div id="tribute_signature_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<span class="field-required"></span><label for="tribute_signaturename">Please enter your first and last name OR group name (50 character limit):</label><small id="signature-caption">Type your name <strong>exactly</strong> as you would
like it to appear in the signature of the tribute card.</small>
<input type="text" name="tribute_signaturename" id="tribute_signaturename" value="" maxlength="70"><small id="signature-name-char-count">0/50 characters</small>
<input type="hidden" name="tribute_signaturesubmit_skip" id="tribute_signaturesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_signature', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_signature_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_signature'));
</script><noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_name_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<span class="field-required"></span><label for="tribute_notify_recip_namename">Tribute Recipient Name:</label>
<input type="text" name="tribute_notify_recip_namename" id="tribute_notify_recip_namename" value="" maxlength="70">
<input type="hidden" name="tribute_notify_recip_namesubmit_skip" id="tribute_notify_recip_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_notify_recip_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_notify_recip_name_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('tribute_show_honor_fields.true', new ComponentDisplayer('tribute_notify_recip_name'));
</script><noscript> </noscript>
</div>
</div>
<div class="custom-field-container form-row ">
<div class="form-content">
<div class="form-input-label-block">
<label for="in_care_of_input">In Care Of</label>
</div>
<input type="text" name="in_care_of_input" id="in_care_of_input" value="" maxlength="255">
<input type="hidden" name="in_care_ofsubmit" id="in_care_ofsubmit" value="true">
</div>
</div>
<div class="custom-field-container form-row ">
<div class="form-content">
<div class="form-input-label-block">
<span class="field-required"></span><label for="honor_memorial_notification_st_input">Tribute Recipient Street:</label>
</div>
<input type="text" name="honor_memorial_notification_st_input" id="honor_memorial_notification_st_input" value="" maxlength="255">
<input type="hidden" name="honor_memorial_notification_stsubmit" id="honor_memorial_notification_stsubmit" value="true">
</div>
</div>
<div class="custom-field-container form-row ">
<div class="form-content">
<div class="form-input-label-block">
<span class="field-required"></span><label for="honormemorialnotification_city_input">Tribute Recipient City:</label>
</div>
<input type="text" name="honormemorialnotification_city_input" id="honormemorialnotification_city_input" value="" maxlength="255">
<input type="hidden" name="honormemorialnotification_citysubmit" id="honormemorialnotification_citysubmit" value="true">
</div>
</div>
<div class="custom-field-container form-row ">
<div class="form-content">
<div class="form-input-label-block">
<span class="field-required"></span><label for="honormemorialnotificationstate_dropdown">Tribute Recipient State/Province:</label>
</div>
<select name="honormemorialnotificationstate_dropdown" id="honormemorialnotificationstate_dropdown" size="1">
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AR">AR</option>
<option value="AZ">AZ</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('honormemorialnotificationstate_dropdown', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('honormemorialnotificationstate_dropdown_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="honormemorialnotificationstatesubmit" id="honormemorialnotificationstatesubmit" value="true">
</div>
</div>
<div class="custom-field-container form-row ">
<div class="form-content">
<div class="form-input-label-block">
<span class="field-required"></span><label for="honormemorialnotification_zip_input">Tribute Recipient ZIP/Postal Code:</label>
</div>
<input type="text" name="honormemorialnotification_zip_input" id="honormemorialnotification_zip_input" value="" maxlength="10">
<input type="hidden" name="honormemorialnotification_zipsubmit" id="honormemorialnotification_zipsubmit" value="true">
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<!-- REQUIRED CONTROL FOR THE MAIL CARD OPTION -->
<!-- DO NOT REMOVE -->
<div id="preview-mail-card-container">
<span id="preview-mail-card-button"> Card Preview </span>
</div>
</div>
</div>
</div>
<h2 class="section-header-container"> Payment Information </h2>
<div class="payment-type-element-container">
<div class="payment-type-selection-container payment-field-container">
<h3>Payment Method:</h3>
<div id="responsive_payment_typepay_typeradio_row" class="form-row">
<div class="form-content">
<div class="payment-type-selections" id="responsive_payment_typepay_typeradio_payment_types">
<span class="internal-payment"></span>
<span class="external-payment"></span>
<div id="payment-type-wrapper"><span class="payment-type-option selected"><input type="radio" name="responsive_payment_typepay_typeradio" id="responsive_payment_typepay_typeradiocredit" value="credit" checked="checked"
onclick="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" onkeypress="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);"><label for="responsive_payment_typepay_typeradiocredit"><img
src="https://secure.info-komen.org/images/content/pagebuilder/blank_space.png" class="payment_type_img" id="img_cc"></label>
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_typepay_typeradio', 'name');
</script><noscript> </noscript>
</span><span class="payment-type-option"><input type="radio" name="responsive_payment_typepay_typeradio" id="responsive_payment_typepay_typeradioach" value="ach"
onclick="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" onkeypress="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);"><label for="responsive_payment_typepay_typeradioach"><img
src="https://secure.info-komen.org/images/content/pagebuilder/blank_space.png" class="payment_type_img" id="img_ach"></label>
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_typepay_typeradio', 'name');
</script><noscript> </noscript>
</span><span class="payment-type-option"><input type="radio" name="responsive_payment_typepay_typeradio" id="responsive_payment_typepay_typeradiopaypal" value="paypal"
onclick="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" onkeypress="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);"><label
for="responsive_payment_typepay_typeradiopaypal"><a href="javascript:void(0);" class="payment-type-label"><img src="https://secure.info-komen.org/images/content/pagebuilder/blank_space.png" alt="Pay with Paypal" class="payment_type_img" id="img_pp"></a></label>
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_typepay_typeradio', 'name');
</script><noscript> </noscript>
</span></div>
</div>
<input type="hidden" name="responsive_payment_typepay_typeradiosubmit" id="responsive_payment_typepay_typeradiosubmit" value="true">
<script type="text/javascript">
Y.use("jquery-ui", function(Y) {
jQuery(function() {
// subscribe observable for payment type options
jQuery('.payment-type-option').each(function() {
var syncAction = function(obj) {
if (obj.hasClass('selected')) {
var radioGroupName = obj.find('input').attr('name');
obj.find('input').prop('checked', true);
fire_obs_comp_event(radioGroupName, obj.find('input').get());
}
return arguments.callee;
}(jQuery(this));
jQuery(this).click(function() {
jQuery('.payment-type-option').removeClass('selected');
jQuery(this).addClass('selected');
syncAction(jQuery(this));
var selectedValue = jQuery(this).find('input').val();
if (selectedValue == 'paypal' || selectedValue == 'amazon') {
// open up a boxinator dialog
jQuery(document).trigger('redirect-external');
jQuery('#btn_next').click();
}
});
});
});
});
var comp = new ObservableRadioComponent('responsive_payment_typepay_typeradio', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typepay_typeradio_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div class="form-row" id="payment-section-disclaimer">
<p>All transactions conducted on this website are encrypted using a secure server to protect your privacy. <a href="https://www.komen.org/privacy-policy/" target="_blank">View Privacy Policy.</a></p>
</div>
</div>
<div id="payment_cc_container" class="payment-field-container" data-private="redact">
<h3>Credit Card Information:</h3>
<div id="responsive_payment_typecc_type_row" class="form-row form-radio-array">
<div class="form-content">
<fieldset>
<legend>Credit Card Type:</legend>
<ul class="radio-array-list">
<li class="tender-row ">
<img src="../images/discovercard_sm.gif" alt="Discover" name="responsive_payment_typecc_type_Discover" id="responsive_payment_typecc_type_Discover">
</li>
<li class="tender-row ">
<img src="../images/amex_small.gif" alt="American Express" name="responsive_payment_typecc_type_American_Express" id="responsive_payment_typecc_type_American_Express">
</li>
<li class="tender-row ">
</li>
<li class="tender-row ">
<img src="../images/mastercd_small.gif" alt="MasterCard" name="payment_typecc_type_MasterCard" id="payment_typecc_type_MasterCard">
</li>
<li class="tender-row ">
<img src="../images/visa_small.gif" alt="Visa" name="payment_typecc_type_Visa" id="payment_typecc_type_Visa">
</li>
</ul>
</fieldset>
<input type="hidden" name="responsive_payment_typecc_typesubmit" id="responsive_payment_typecc_typesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_typecc_type', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_type_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typecc_number_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typecc_numbername">Credit Card Number:</label>
<input type="text" name="responsive_payment_typecc_numbername" id="responsive_payment_typecc_numbername" value="" maxlength="16" autocomplete="off" pattern="[0-9]*" required="required">
<input type="hidden" name="responsive_payment_typecc_numbersubmit" id="responsive_payment_typecc_numbersubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typecc_number', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_number_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('null', new ComponentDisplayer('responsive_payment_typecc_number'));
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typecc_exp_date_row" class="form-row form-date">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typecc_exp_date_MONTH">
<span class="label-text">Expiration Date:</span><span class="aural-only">Select month of credit card</span>
</label>
<label for="responsive_payment_typecc_exp_date_YEAR"><span class="aural-only">Select Expiration Year</span></label>
<div class="date-input-container">
<fieldset class="cardExpGroup">
<select name="responsive_payment_typecc_exp_date_MONTH" id="responsive_payment_typecc_exp_date_MONTH" onchange="fire_obs_comp_event('responsive_payment_typecc_exp_date_MONTH', this)" required="required">
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4" selected="selected">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>
<select name="responsive_payment_typecc_exp_date_YEAR" id="responsive_payment_typecc_exp_date_YEAR" onchange="fire_obs_comp_event('responsive_payment_typecc_exp_date_YEAR', this)" required="required">
<option value="2023" selected="selected">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>
<option value="2033">2033</option>
</select>
</fieldset>
<input type="hidden" name="responsive_payment_typecc_exp_date_DAY" id="responsive_payment_typecc_exp_date_DAY" value="1">
<script type="text/javascript">
<!--
var comp1 = new ObservableComponent('responsive_payment_typecc_exp_date_MONTH', '');
comp1.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_exp_date_Row', _display);
this.disable_submit_flag(_hidden);
}
var comp2 = new ObservableComponent('responsive_payment_typecc_exp_date_YEAR', '');
comp2.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_exp_date_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script><noscript> </noscript>
</div>
<input type="hidden" name="responsive_payment_typecc_exp_datesubmit" id="responsive_payment_typecc_exp_datesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typecc_exp_date', 'input');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_exp_date_row', _display);
disable_submit_flag('responsive_payment_typecc_exp_datesubmit', _hidden);
}
comp.disable = function(_disabled) {
disable_element('responsive_payment_typecc_exp_date_MONTH', _disabled);
disable_element('responsive_payment_typecc_exp_date_DAY', _disabled);
disable_element('responsive_payment_typecc_exp_date_YEAR', _disabled);
disable_element('responsive_payment_typecc_exp_date_HOUR12', _disabled);
disable_element('responsive_payment_typecc_exp_date_HOUR24', _disabled); //For UK, 24 hour clock used
disable_element('responsive_payment_typecc_exp_date_MINUTE', _disabled);
disable_element('responsive_payment_typecc_exp_date_AMPM', _disabled);
}
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typecc_cvv_row" class="form-row form-text cvv-input">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typecc_cvvname">
<span class="FormLabelText">CVV Number:</span>
</label><span id="cvv-info">i</span>
<input type="text" name="responsive_payment_typecc_cvvname" id="responsive_payment_typecc_cvvname" value="" maxlength="4" autocomplete="cc-csc" pattern="[0-9]*" required="required">
<input type="hidden" name="responsive_payment_typecc_cvvsubmit" id="responsive_payment_typecc_cvvsubmit" value="true">
<script type="text/javascript">
//chrome is mapping cvv as card name
if (/Chrome/.test(navigator.userAgent) && /Google Inc/.test(navigator.vendor)) {
document.getElementById('responsive_payment_typecc_cvvname').autocomplete = 'cc-csc';
}
var comp = new ObservableComponent('responsive_payment_typecc_cvv', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_cvv_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
</div>
<div id="payment_bank_container" class="payment-field-container" style="display: none;" data-private="redact">
<h3>Checking Account Information:</h3>
<div id="responsive_payment_typerouting_number_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typerouting_numbername">Bank Routing Number:</label>
<a href="http://help.convio.net/site/PageServer?s_site=kd&pagename=User_Donation_ACH" class="HelpLink" title="What is this? Opens new window.">What is this?</a>
<input type="text" name="responsive_payment_typerouting_numbername" id="responsive_payment_typerouting_numbername" value="" size="20" maxlength="20" onchange="fire_obs_comp_event('responsive_payment_typerouting_number', this);"
autocomplete="off">
<input type="hidden" name="responsive_payment_typerouting_numbersubmit" id="responsive_payment_typerouting_numbersubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typerouting_number', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typerouting_number_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typebank_account_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typebank_accountname">Bank Account Number:</label>
<input type="text" name="responsive_payment_typebank_accountname" id="responsive_payment_typebank_accountname" value="" maxlength="20" autocomplete="off">
<input type="hidden" name="responsive_payment_typebank_accountsubmit" id="responsive_payment_typebank_accountsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typebank_account', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typebank_account_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('null', new ComponentDisplayer('responsive_payment_typebank_account'));
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typeverify_bank_account_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typeverify_bank_accountname">Verify Bank Account Number:</label>
<input type="text" name="responsive_payment_typeverify_bank_accountname" id="responsive_payment_typeverify_bank_accountname" value="" maxlength="20" autocomplete="off">
<input type="hidden" name="responsive_payment_typeverify_bank_accountsubmit" id="responsive_payment_typeverify_bank_accountsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typeverify_bank_account', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typeverify_bank_account_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('null', new ComponentDisplayer('responsive_payment_typeverify_bank_account'));
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_type.account_type_row" class="form-row form-radio-array">
<div class="form-content">
<fieldset>
<legend><span class="field-required"></span> Account Type:</legend>
<ul class="radio-array-list">
<li>
<input type="radio" name="responsive_payment_type.account_type" id="responsive_payment_type.account_type_responsive_payment_typeaccount_type_checking" value="CHECKING"
onclick="fire_obs_comp_event('responsive_payment_type.account_type', this);">
<span class="radio-label">
<label for="responsive_payment_type.account_type_responsive_payment_typeaccount_type_checking">Checking</label>
</span>
</li>
<li>
<input type="radio" name="responsive_payment_type.account_type" id="responsive_payment_type.account_type_responsive_payment_typeaccount_type_savings" value="SAVINGS"
onclick="fire_obs_comp_event('responsive_payment_type.account_type', this);">
<span class="radio-label">
<label for="responsive_payment_type.account_type_responsive_payment_typeaccount_type_savings">Savings</label>
</span>
</li>
</ul>
</fieldset>
<input type="hidden" name="responsive_payment_type.account_typesubmit" id="responsive_payment_type.account_typesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_type.account_type', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_type.account_type_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typeach_confirm_row" class="form-row form-checkbox">
<div class="form-content">
<span class="field-required"></span>
<input type="checkbox" name="responsive_payment_typeach_confirmname" id="responsive_payment_typeach_confirmname" onclick="fire_obs_comp_event('responsive_payment_typeach_confirm', this);">
<label for="responsive_payment_typeach_confirmname">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>
<input type="hidden" name="responsive_payment_typeach_confirmsubmit" id="responsive_payment_typeach_confirmsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typeach_confirm', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typeach_confirm_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('responsive_payment_typeach_confirmname')) {
document.getElementById('responsive_payment_typeach_confirmname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('responsive_payment_typeach_confirmname')) {
return document.getElementById('responsive_payment_typeach_confirmname').checked;
}
}
comp.clear = function() {
this.set(false);
}
observe_component('null', new ComponentEnabler('responsive_payment_typeach_confirm'));
</script><noscript> </noscript>
</div>
</div>
</div>
<div id="payment_check_container" class="payment-field-container" style="display: none;" data-private="redact">
<h3>Check Information</h3>
</div>
<input type="hidden" name="responsive_payment_typesubmit" id="responsive_payment_typesubmit" value="true">
<script type="text/javascript">
function PaymentObserver() {
this.observe = function(_event) {
var sVal = _event.component.get();
switch (sVal) {
case 'check':
hide_element('payment_cc_container');
hide_element('payment_bank_container');
show_element('payment_check_container');
break;
case 'credit':
hide_element('payment_bank_container');
hide_element('payment_check_container');
show_element('payment_cc_container');
break;
case 'ach':
hide_element('payment_cc_container');
hide_element('payment_check_container');
show_element('payment_bank_container');
break;
case 'paypal':
case 'amazon':
case 'mobilepay':
default:
// hide all
hide_element('payment_bank_container');
hide_element('payment_cc_container');
hide_element('payment_check_container');
break;
}
}
}
// Set the observer to show/hide the relevant fields
observe_component('responsive_payment_typepay_typeradio', new PaymentObserver());
</script><noscript> </noscript>
</div>
<div class="custom-field-container form-row ">
<div class="form-content">
<div class="form-input-label-block" style="display: none;">
<label for="cover_fees_dropdown">(I choose to add $0.00 to cover the fees to process my donation.)</label>
</div>
<fieldset>
<input type="checkbox" name="cover_fees_radio" id="cover_fees_radio" value="">
<label class="custom-element-checkbox-label" for="cover_fees_radio">(I choose to add <span id="fee-amount">$4.00</span> to cover the fees to process my donation.)</label>
</fieldset>
<input type="hidden" name="cover_feessubmit" id="cover_feessubmit" value="true">
</div>
</div>
<div class="custom-field-container form-row " style="display: none;">
<div class="form-content">
<div class="form-input-label-block">
<label for="cover_fees_amount_input">Cover Fees Amount</label>
</div>
<input type="text" name="cover_fees_amount_input" id="cover_fees_amount_input" value="" maxlength="255">
<input type="hidden" name="cover_fees_amountsubmit" id="cover_fees_amountsubmit" value="true">
</div>
</div>
<h2 class="section-header-container"> Your information </h2>
<div id="billing_first_name_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_first_namename">First Name:</label>
<input type="text" name="billing_first_namename" id="billing_first_namename" value="" maxlength="50" required="required">
<input type="hidden" name="billing_first_namesubmit" id="billing_first_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_first_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_first_name_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_last_name_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_last_namename">Last Name:</label>
<input type="text" name="billing_last_namename" id="billing_last_namename" value="" maxlength="50" required="required">
<input type="hidden" name="billing_last_namesubmit" id="billing_last_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_last_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_last_name_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="donor_email_address_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="donor_email_addressname">Email Address:</label>
<input type="text" name="donor_email_addressname" id="donor_email_addressname" value="" maxlength="255" required="required">
<input type="hidden" name="donor_email_addresssubmit" id="donor_email_addresssubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_email_address', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_email_address_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="donor_phone_row" class="form-row form-text">
<div class="form-content">
<label for="donor_phonename">Mobile Phone:</label>
<input type="text" name="donor_phonename" id="donor_phonename" value="" maxlength="50">
<input type="hidden" name="donor_phonesubmit" id="donor_phonesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_phone', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_phone_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="donor_phone_type_row" class="form-row form-selectlist">
<div class="form-content">
<label class="FormLabel" for="donor_phone_type">Donor Phone Type:</label>
<select name="donor_phone_type" id="donor_phone_type" size="1">
<option value="home_phone">Home Phone</option>
<option value="work_phone">Work Phone</option>
<option selected="selected" value="mobile_phone">Mobile Phone</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('donor_phone_type', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_phone_type_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="donor_phone_typesubmit" id="donor_phone_typesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_phone_type', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_phone_type_row', _display);
this.disable_submit_flag(_hidden);
}
function donor_phone_type_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('donor_phone_type', src);
}
}
var el = document.getElementById('donor_phone_type');
if (el) {
Utils.addEvent(el, 'change', donor_phone_type_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<h2 class="section-header-container"> Billing Information </h2>
<div id="billing_addr_country_row" class="form-row form-selectlist">
<div class="form-content"><span id="country-name-display">Your default country is United States</span><span id="country-name-save">Save</span><span id="country-name-edit">Edit</span>
<select name="billing_addr_country" id="billing_addr_country" size="1" onchange="fire_obs_comp_event('billing_addr_country', this)">
<option></option>
<option selected="selected" value="United States">United States</option>
<option value="Afghanistan">Afghanistan</option>
<option value="Aland Islands">Aland Islands</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antarctica">Antarctica</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia, Plurinational State of">Bolivia, Plurinational State of</option>
<option value="Bonaire, Sint Eustatius and Saba">Bonaire, Sint Eustatius and Saba</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet Island">Bouvet Island</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
<option value="Brunei Darussalam">Brunei Darussalam</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cape Verde">Cape Verde</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="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="Curacao">Curacao</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="Guernsey">Guernsey</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option>
<option value="Holy See (Vatican City State)">Holy See (Vatican City State)</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran, Islamic Republic of">Iran, Islamic Republic of</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Isle of Man">Isle of Man</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jersey">Jersey</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="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="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macao">Macao</option>
<option value="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="Montenegro">Montenegro</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestine, State of">Palestine, State of</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 Barthelemy">Saint Barthelemy</option>
<option value="Saint Helena, Ascension and Tristan da Cunha">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Martin (French Part)">Saint Martin (French Part)</option>
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia">Serbia</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Sint Maarten (Dutch Part)">Sint Maarten (Dutch Part)</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="South Sudan">South Sudan</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
<option value="Swaziland">Swaziland</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syrian Arab Republic">Syrian Arab Republic</option>
<option value="Taiwan, Province of China">Taiwan, Province of China</option>
<option value="Tajikistan">Tajikistan</option>
<option value="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 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, Bolivarian Republic of">Venezuela, Bolivarian Republic of</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>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('billing_addr_country', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_country_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="billing_addr_countrysubmit" id="billing_addr_countrysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_country', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_country_row', _display);
this.disable_submit_flag(_hidden);
}
function billing_addr_country_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('billing_addr_country', src);
}
}
var el = document.getElementById('billing_addr_country');
if (el) {
Utils.addEvent(el, 'change', billing_addr_country_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_street1_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_addr_street1name">Street 1:</label>
<input type="text" name="billing_addr_street1name" id="billing_addr_street1name" value="" maxlength="50" required="required" class="pac-target-input" placeholder="Geben Sie einen Standort ein." autocomplete="off">
<input type="hidden" name="billing_addr_street1submit" id="billing_addr_street1submit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_street1', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_street1_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_city_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_addr_cityname">City:</label>
<input type="text" name="billing_addr_cityname" id="billing_addr_cityname" value="" maxlength="50" required="required">
<input type="hidden" name="billing_addr_citysubmit" id="billing_addr_citysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_city', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_city_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_state_row" class="form-row form-selectlist">
<div class="form-content">
<span class="field-required"></span>
<label class="FormLabel" for="billing_addr_state">State/Province:</label>
<select name="billing_addr_state" id="billing_addr_state" size="1" onchange="fire_obs_comp_event('billing_addr_state', this)" required="required">
<option></option>
<option value="AK">AK - Alaska</option>
<option value="AL">AL - Alabama</option>
<option value="AR">AR - Arkansas</option>
<option value="AZ">AZ - Arizona</option>
<option value="CA">CA - California</option>
<option value="CO">CO - Colorado</option>
<option value="CT">CT - Connecticut</option>
<option value="DC">DC - District of Columbia</option>
<option value="DE">DE - Delaware</option>
<option value="FL">FL - Florida</option>
<option value="GA">GA - Georgia</option>
<option value="HI">HI - Hawaii</option>
<option value="IA">IA - Iowa</option>
<option value="ID">ID - Idaho</option>
<option value="IL">IL - Illinois</option>
<option value="IN">IN - Indiana</option>
<option value="KS">KS - Kansas</option>
<option value="KY">KY - Kentucky</option>
<option value="LA">LA - Louisiana</option>
<option value="MA">MA - Massachusetts</option>
<option value="MD">MD - Maryland</option>
<option value="ME">ME - Maine</option>
<option value="MI">MI - Michigan</option>
<option value="MN">MN - Minnesota</option>
<option value="MO">MO - Missouri</option>
<option value="MS">MS - Mississippi</option>
<option value="MT">MT - Montana</option>
<option value="NC">NC - North Carolina</option>
<option value="ND">ND - North Dakota</option>
<option value="NE">NE - Nebraska</option>
<option value="NH">NH - New Hampshire</option>
<option value="NJ">NJ - New Jersey</option>
<option value="NM">NM - New Mexico</option>
<option value="NV">NV - Nevada</option>
<option value="NY">NY - New York</option>
<option value="OH">OH - Ohio</option>
<option value="OK">OK - Oklahoma</option>
<option value="OR">OR - Oregon</option>
<option value="PA">PA - Pennsylvania</option>
<option value="RI">RI - Rhode Island</option>
<option value="SC">SC - South Carolina</option>
<option value="SD">SD - South Dakota</option>
<option value="TN">TN - Tennessee</option>
<option value="TX">TX - Texas</option>
<option value="UT">UT - Utah</option>
<option value="VA">VA - Virginia</option>
<option value="VT">VT - Vermont</option>
<option value="WA">WA - Washington</option>
<option value="WI">WI - Wisconsin</option>
<option value="WV">WV - West Virginia</option>
<option value="WY">WY - Wyoming</option>
<option value="AS">AS - American Samoa</option>
<option value="FM">FM - Federated States of Micronesia</option>
<option value="GU">GU - Guam</option>
<option value="MH">MH - Marshall Islands</option>
<option value="MP">MP - Northern Mariana Islands</option>
<option value="PR">PR - Puerto Rico</option>
<option value="PW">PW - Palau</option>
<option value="VI">VI - Virgin Islands</option>
<option value="AA">AA - Armed Forces Americas</option>
<option value="AE">AE - Armed Forces</option>
<option value="AP">AP - Armed Forces Pacific</option>
<option value="AB">AB - Alberta</option>
<option value="BC">BC - British Columbia</option>
<option value="MB">MB - Manitoba</option>
<option value="NB">NB - New Brunswick</option>
<option value="NL">NL - Newfoundland and Labrador</option>
<option value="NS">NS - Nova Scotia</option>
<option value="NT">NT - Northwest Territories</option>
<option value="NU">NU - Nunavut</option>
<option value="ON">ON - Ontario</option>
<option value="QC">QC - Quebec</option>
<option value="SK">SK - Saskatchewan</option>
<option value="YT">YT - Yukon</option>
<option value="None">None</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('billing_addr_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_state_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="billing_addr_statesubmit" id="billing_addr_statesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_state_row', _display);
this.disable_submit_flag(_hidden);
}
function billing_addr_state_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('billing_addr_state', src);
}
}
var el = document.getElementById('billing_addr_state');
if (el) {
Utils.addEvent(el, 'change', billing_addr_state_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_zip_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_addr_zipname">ZIP/Postal Code:</label>
<input type="text" name="billing_addr_zipname" id="billing_addr_zipname" value="" maxlength="10" required="required">
<input type="hidden" name="billing_addr_zipsubmit" id="billing_addr_zipsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_zip', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_zip_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<h2 style="border: none;font-size: 22px;font-family: 'Montserrat', sans-serif;font-weight: 400;margin-bottom: 12px;"> Would you like your employer to match your gift? If so, please search below. </h2>
<style>
.dd-company-selected .wrongcompany {
display: block;
}
.dd-company-selected .wrongcompany a {
color: #c5006e !important;
font-family: 'Montserrat', sans-serif;
font-size: 16px;
font-weight: 400;
}
</style>
<script src="https://doublethedonation.com/api/js/ddplugin.js"></script>
<link href="https://doublethedonation.com/api/css/ddplugin.css" rel="stylesheet">
<div id="dd-company-name-input" data-doublethedonation-widget-id="G__2">
<div class="dtd-streamlined-plugin"><input type="hidden" name="doubledonation_status" value="no_interaction"><input type="hidden" name="doublethedonation_status" value="no_interaction"><input type="hidden"
name="doublethedonation_entered_text"><input type="hidden" name="doubledonation_company_id"><input type="hidden" name="doublethedonation_company_id"><input type="hidden" name="doubledonation_company_name"><input type="hidden"
name="doublethedonation_company_name">
<div class="dtd-search-box" style="width: 100%; margin-bottom: 0px;">
<div aria-live="assertive" style="display: block; font-size: 0px; color: rgb(255, 255, 255); opacity: 0; position: absolute; height: 0px; margin: 0px; z-index: -99999;"></div>
<div aria-live="polite" style="display: block; font-size: 0px; color: rgb(255, 255, 255); opacity: 0; position: absolute; height: 0px; margin: 0px; z-index: -99999;"></div><input role="listbox" aria-expanded="false"
name="doublethedonation_company_name_input" autocomplete="new-password" type="text" id="dd-input" class="dtd-search-input form-control BBFormTextbox" aria-label="Search company" style="width: 100%;"
placeholder="Search company name...">
</div>
</div>
</div>
<script type="text/javascript">
// <![CDATA[
if (window.doublethedonation) {
console.log('DOUBLE THE DONATION LOADED');
var targetNodeTimer = setInterval(function() {
var targetNode = document.querySelector('#dd-company-name-input > div > input[name="doublethedonation_company_id"]');
if (targetNode != null) {
// Options for the observer (which mutations to observe)
var config = {
attributes: true
};
// Callback function to execute when mutations are observed
var callback = function(mutationsList, observer) {
var mutation = mutationsList[mutationsList.length - 1];
if (mutation.type === 'attributes' && mutation.attributeName === 'value') {
console.log('Company changed');
var dtd_company_id = document.querySelector('input[name="doublethedonation_company_id"]').value;
console.log('Selected company ID: ' + dtd_company_id);
document.getElementById('double_the_donation_company_idhidden').value = dtd_company_id;
}
};
// Create an observer instance linked to the callback function
var observer = new MutationObserver(callback);
// Start observing the target node for configured mutations
observer.observe(targetNode, config);
// Clear the timer
clearInterval(targetNodeTimer);
}
}, 100);
}
// ]]>
</script>
</div>
</div>
<input type="hidden" name="double_the_donation_company_idhidden" id="double_the_donation_company_idhidden" value="">
<div class="form-row form-checkbox" id="donor_email_opt_in_Row" style="display: none;">
<div class="form-content">
<span class="check-box-form-label-text"></span>
<input type="checkbox" name="donor_email_opt_inname" id="donor_email_opt_inname" checked="checked" onclick="fire_obs_comp_event('donor_email_opt_in', this);">
<label for="donor_email_opt_inname"> Yes, I would like to receive communication from this organization. </label>
<script type="text/javascript">
var comp = new ObservableComponent('donor_email_opt_in', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_email_opt_in_Row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('donor_email_opt_inname')) {
document.getElementById('donor_email_opt_inname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('donor_email_opt_inname')) return document.getElementById('donor_email_opt_inname').checked;
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
<input type="hidden" name="donor_email_opt_insubmit" id="donor_email_opt_insubmit" value="true">
</div>
</div>
<div class="custom-field-container form-row " style="display: none;">
<div class="form-content">
<div class="form-input-label-block">
<label for="mobile_opt_in_dropdown">Mobile Opt In</label>
</div>
<fieldset>
<input type="checkbox" name="mobile_opt_in_radio" id="mobile_opt_in_radio" value="true">
<label class="custom-element-checkbox-label" for="mobile_opt_in_radio">Yes</label>
</fieldset>
<input type="hidden" name="mobile_opt_insubmit" id="mobile_opt_insubmit" value="true">
</div>
</div>
<div class="custom-field-container">
<div class="form-content">
<div class="form-input-label-block">
<label for="communication_opt_in_all_dropdown" style="display: none;">Communication Opt In All</label>
</div>
<fieldset>
<input type="checkbox" name="communication_opt_in_all_radio" id="communication_opt_in_all_radio" value="true">
<label class="custom-element-checkbox-label" for="communication_opt_in_all_radio">I would like to receive additional communication from Susan G. Komen®</label>
</fieldset>
<input type="hidden" name="communication_opt_in_allsubmit" id="communication_opt_in_allsubmit" value="true">
</div>
</div>
<div class="custom-field-container form-row " style="display: none;">
<div class="form-content">
<div class="form-input-label-block">
<label for="tribute_card_send_source_radio_input">Tribute Card Send Source Radio</label>
</div>
<input type="text" name="tribute_card_send_source_radio_input" id="tribute_card_send_source_radio_input" value="" maxlength="255">
<input type="hidden" name="tribute_card_send_source_radiosubmit" id="tribute_card_send_source_radiosubmit" value="true">
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<script>
var tributeCardSourceInput = document.getElementById('tribute_card_send_source_radio_input')
if (tributeCardSourceInput != null) {
tributeCardSourceInput.parentElement.parentElement.style.display = 'none'
}
</script>
</div>
</div>
<div class="custom-field-container form-row " style="display: none;">
<div class="form-content">
<div class="form-input-label-block">
<label for="unique_load_id_input">Unique_Load_ID</label>
</div>
<input type="text" name="unique_load_id_input" id="unique_load_id_input" value="" maxlength="255">
<input type="hidden" name="unique_load_idsubmit" id="unique_load_idsubmit" value="true">
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<script>
var uid
var uniqueIdInput = document.getElementById('unique_load_id_input')
if (!Date.now) {
Date.now = function() {
return new Date().getTime();
}
}
if (uniqueIdInput != null) {
uniqueIdInput.parentElement.parentElement.style.display = 'none'
uid = Date.now().toString(16).toUpperCase() + "_" + Math.floor(Math.random() * 100000)
uniqueIdInput.value = uid
}
</script>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<div id="ecard-preview-overlay" class="container" style="display: none;">
<div id="ecard-container">
<span class="material-icons md-dark block" id="ecard-preview-close">cancel</span>
<div id="ecard-from">
<span>From:</span>
<p></p>
</div>
<div id="ecard-to">
<span>To:</span>
<p></p>
</div>
<div id="ecard-subject">
<span>Subject:</span>
<p></p>
</div>
<div class="ecard-preview-container">
<div class="ecard-top">
<img src="https://www.komen.org/wp-content/uploads/Logo.png" alt="Susan G. Komen">
</div>
<div class="ecard-content">
<div id="ecard-image">
<img src="" alt="">
</div>
<span id="ecard-gift-type-info"> A Gift in Memory of / Honor of </span>
<span id="ecard-honoree-name">
</span>
<p>has been made to</p>
<h3>Susan G. Komen®</h3>
<p>by</p>
<span id="ecard-donor-name">
</span>
<strong style="display: block; text-align: center; color: #ce006b; font-size: 12px; margin-bottom: 1rem;"> Susan G. Komen promises to save lives and end breast cancer by empowering people, ensuring quality care for all and
energizing science to find the cures. </strong>
<small style="display: block; text-align: center; font-style: italic; font-size: 10px;"> The Running Ribbon is a registered trademark of Susan G. Komen. </small>
</div>
</div>
<p id="ecard-preview-message" style="margin: 5px 0;">
</p>
<table style="border-top: 3px solid rgb(198, 0, 112); width: 100%; background-color: #EDEDED;" class="footer-container" bgcolor="#EDEDED" border="0" cellpadding="0" cellspacing="0" width="100%">
<tbody>
<tr>
<td style="padding: 9px 18px; font-family: Arial,Helvetica,sans-serif; font-size: 11px; line-height: 1.125em; color: #1F1F1F;" class="footer" align="left" valign="top">
<table style="float: right; width: 107px;" class="charity-nav-bbb" align="right" border="0" cellpadding="0" cellspacing="0" width="107">
<tbody>
<tr>
<td style="padding: 20px 0px 6px 6px; text-align: right;" align="right" valign="top">
<table style="float: right" align="right" border="0" cellpadding="0" cellspacing="0">
<tbody>
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<td style="padding: 0px; text-align: right;" align="right" valign="top">
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