cparf.salsalabs.org
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Submitted URL: https://default.salsalabs.org/T64767213-cd56-4fe0-8c64-b97c159f4aa3/36253677-eb90-4537-9d87-b6717e245069
Effective URL: https://cparf.salsalabs.org/giveonline/index.html?eType=EmailBlastContent&eId=bc769b81-f358-41db-8002-86fbc860f342
Submission: On July 07 via manual from IN — Scanned from DE
Effective URL: https://cparf.salsalabs.org/giveonline/index.html?eType=EmailBlastContent&eId=bc769b81-f358-41db-8002-86fbc860f342
Submission: On July 07 via manual from IN — Scanned from DE
Form analysis 1 forms found in the DOM
<form class="sli-form fv-form fv-form-salsa" data-fv-framework="salsa" novalidate="novalidate" data-ignite-form-id="da3799e9-2acd-4731-973f-b0ddfebd6433" id="form_ignxSBFaZHZk">
<div class="sli-row" id="id_77c88772-3ff8-4c77-83ed-e6d09bd8c21f">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="elementStep" id="id_2db5b163-e9b1-41e1-b399-a564f5b778fb" data-ignite-step-id="1">
<div class="sli-row" id="id_31ea06ec-6bcc-40f6-a2d7-af29edff4d4a">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_cea6bc4e-e701-4ed3-a6ba-239cb44c7961">
<div class="sli-element sli-image sli-show-for-small-only" id="id_14c052e2-c1b6-4674-b595-43abb4d98066"> <img entity-id="5c835bc4-6992-4264-b529-6eefa293f34d" id="id_14c052e2-c1b6-4674-b595-43abb4d98066_img" max-width="601" align="center"
alt="" src="https://cparf.salsalabs.org/3fe00574-c1a5-4345-b42b-97420110073e/5c835bc4-6992-4264-b529-6eefa293f34d.png"
ignite-image-src="https://cparf.salsalabs.org/3fe00574-c1a5-4345-b42b-97420110073e/5c835bc4-6992-4264-b529-6eefa293f34d.png"> </div>
<div class="sli-row" id="id_56cffcec-24e6-417b-8e74-5a8da480f918">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_e915699a-4232-473b-952a-be47eb8409fd">
<div class="sli-element sli-image sli-show-for-small-only" id="id_a06f5ff0-02ae-469c-9dd3-4ff97f1ef427"> <img entity-id="714b6c74-ad7d-4eca-b74e-691af708ae8d" id="id_a06f5ff0-02ae-469c-9dd3-4ff97f1ef427_img" max-width="1080"
align="center" alt="" src="https://cparf.salsalabs.org/3fe00574-c1a5-4345-b42b-97420110073e/714b6c74-ad7d-4eca-b74e-691af708ae8d.jpg"
ignite-image-src="https://cparf.salsalabs.org/3fe00574-c1a5-4345-b42b-97420110073e/714b6c74-ad7d-4eca-b74e-691af708ae8d.jpg"> </div>
</div>
</div>
</div>
</div>
<div class="sli-element sli-text sli-align-center-for-small sli-text-left-for-small" id="id_16c667b1-cf57-4a8c-b1f3-3574e9898855">
<div id="id_16c667b1-cf57-4a8c-b1f3-3574e9898855_inner">
<h2> <strong>Donate Online</strong> </h2>
<p> <span style="font-size: 16px;">This is the fastest way to make an impact on cerebral palsy research and disability innovation. Make your gift online today to move Cerebral Palsy Alliance Research Foundation's work
forward.</span> </p>
</div>
</div>
<div class="sli-element sli-divider-element" id="id_7e905f6d-dbc9-4dd0-8ce2-2fc9033d7754">
<div class="sli-divider"> </div>
</div>
<div class="sli-row" id="id_99256099-f8df-4fc6-9a6f-d56e1d1ca344">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_6580421d-f5c4-43be-84c5-92b70033eb9d">
<div class="sli-donorPaysFees sli-element " id="id_d5c5a4e5-9df7-480e-8eca-906e3ecdf890_kavJsSheyX" data-ignite-field-id="DonorPaysFees"> <label class="sli-label"
for="id_d5c5a4e5-9df7-480e-8eca-906e3ecdf890_kavJsSheyX_donorPaysFees_input"><input class="sli-input" id="id_d5c5a4e5-9df7-480e-8eca-906e3ecdf890_kavJsSheyX_donorPaysFees_input" type="checkbox" name="donorPaysFees" value="true"
style="margin-right: 5px;" salsa-reference-name="donorpaysfeescb">Increase my donation amount to cover fees.</label> </div>
<div class="sli-row" id="id_e0a9128a-1829-40a9-9cd7-7f225277c0a3">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_6a255602-26e0-4666-844a-96c2a0db5ac9">
<div class="sli-selectRecurring sli-element " id="id_22b94d1e-8f67-47ed-bf17-9ef8c3f69907_nDYbMWchef" data-ignite-field-id="MakeRecurring"> <label class="sli-label"
for="id_22b94d1e-8f67-47ed-bf17-9ef8c3f69907_nDYbMWchef_makeRecurring_input"><input class="sli-input" id="id_22b94d1e-8f67-47ed-bf17-9ef8c3f69907_nDYbMWchef_makeRecurring_input" type="checkbox" name="makeRecurring" value="true"
style="margin-right: 5px;" salsa-reference-name="makerecurringcb">Make this a monthly donation.</label> </div>
</div>
</div>
<div class="sli-donation-amountblock sli-element" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2" data-ignite-enable-onetime="true" data-ignite-enable-recurring-amounts="true" data-ignite-field-id="DonationAmount">
<div class="sli-donationAmounts">
<div class="sli-oneTimeDonation" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_oneTime" data-ignite-onetime-amount="data-ignite-onetime-amount">
<ul class="sli-oneTimeDonationAmounts sli-style-button" style="justify-content: flex-start;">
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_onetime_amt_25" type="radio" data-ignite-amount="25.00" data-fv-onetimeamount="true"
data-sli-widget="_ignxSBFaZHZk" data-fv-row=".sli-oneTimeDonation" data-fv-err-container=".sli-oneTimeDonationError" data-fv-onetimeamount-message="Please select a donation amount, or enter your own amount"
data-fv-field="donationAmtToggle"><label class="sli-oneTimeAmountLabel sli-amount-label sli-small sli-push" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_onetime_amt_25_label"
for="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_onetime_amt_25">$25</label></li>
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_onetime_amt_50" type="radio" data-ignite-amount="50.00" data-fv-field="donationAmtToggle"
data-sli-widget="_ignxSBFaZHZk"><label class="sli-oneTimeAmountLabel sli-amount-label sli-small sli-push" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_onetime_amt_50_label"
for="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_onetime_amt_50">$50</label></li>
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_onetime_amt_100" type="radio" data-ignite-amount="100.00" data-fv-field="donationAmtToggle"
data-sli-widget="_ignxSBFaZHZk"><label class="sli-oneTimeAmountLabel sli-amount-label sli-small sli-push" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_onetime_amt_100_label"
for="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_onetime_amt_100">$100</label></li>
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_onetime_amt_200" type="radio" data-ignite-amount="200.00" data-fv-field="donationAmtToggle"
data-sli-widget="_ignxSBFaZHZk"><label class="sli-oneTimeAmountLabel sli-amount-label sli-small sli-push" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_onetime_amt_200_label"
for="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_onetime_amt_200">$200</label></li>
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_onetime_amt_500" type="radio" data-ignite-amount="500.00" data-fv-field="donationAmtToggle"
data-sli-widget="_ignxSBFaZHZk"><label class="sli-oneTimeAmountLabel sli-amount-label sli-small sli-push" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_onetime_amt_500_label"
for="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_onetime_amt_500">$500</label></li>
<li style=" display: block;"><input class="sli-oneTimeAmountRadio sli-oneTimeCustomAmount" name="donationAmtToggleOther" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_onetime_custom_radio" type="radio"
data-ignite-custom-onetime="data-ignite-custom-onetime" aria-label="custom one-time donation amount" data-sli-widget="_ignxSBFaZHZk">
<div class="sli-input-group"> <label class="sli-oneTimeAmountLabel sli-amount-label sli-customAmount sli-input-group-label sli-small sli-push" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_onetime_custom_label"
for="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_onetime_custom" autocomplete="off">$</label> <input class="sli-oneTimeAmountInput sli-customAmount sli-input sli-input-group-field" size="5"
id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_onetime_custom" type="text" placeholder="Other" name="customOneTime" autocomplete="off" data-ignite-custom-onetime-input="donationAmtToggle"
data-fv-row=".sli-oneTimeDonation" data-fv-err-container=".sli-oneTimeDonationError" data-fv-numeric="true" data-fv-numeric-message="Please enter a dollar amount" data-fv-notempty="true"
data-fv-notempty-message="An amount is required" data-fv-greaterthan="true" data-fv-greaterthan-inclusive="false" data-fv-greaterthan-value="0.0" data-fv-greaterthan-message="Please enter a positive amount"
data-fv-field="customOneTime"> </div>
</li>
</ul>
<div class="sli-oneTimeDonationError sli-field-error"><small class="sli-field-error" data-fv-validator="onetimeAmount" data-fv-for="donationAmtToggle" data-fv-result="NOT_VALIDATED" style="display: none;">Please select a donation
amount, or enter your own amount</small><small class="sli-field-error" data-fv-validator="greaterThan" data-fv-for="customOneTime" data-fv-result="NOT_VALIDATED" style="display: none;">Please enter a positive amount</small><small
class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="customOneTime" data-fv-result="NOT_VALIDATED" style="display: none;">An amount is required</small><small class="sli-field-error" data-fv-validator="numeric"
data-fv-for="customOneTime" data-fv-result="NOT_VALIDATED" style="display: none;">Please enter a dollar amount</small></div>
</div>
<div class="sli-recurringDonation" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurring" data-ignite-recurring-amount="data-ignite-recurring-amount" style="display:none;">
<p data-ignite-recurrence-frequency="Monthly" class=" sli-recurringFrequency" style="margin: 0;">Donation will repeat monthly.</p>
<ul class="sli-recurringDonationAmounts sli-style-button" style="justify-content: flex-start;">
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurringAmt_10" type="radio" data-ignite-amount="10.00" data-fv-recurringamount="true"
data-sli-widget="_ignxSBFaZHZk" data-fv-row=".sli-recurringDonation" data-fv-err-container=".sli-recurringDonationError" data-fv-recurringamount-message="Please select a donation amount, or enter your own amount"
data-fv-field="donationAmtToggle2"><label class="sli-recurringAmountLabel sli-amount-label sli-small sli-push" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurringAmt_10_label"
for="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurringAmt_10">$10</label></li>
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurringAmt_25" type="radio" data-ignite-amount="25.00" data-fv-field="donationAmtToggle2"
data-sli-widget="_ignxSBFaZHZk"><label class="sli-recurringAmountLabel sli-amount-label sli-small sli-push" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurringAmt_25_label"
for="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurringAmt_25">$25</label></li>
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurringAmt_50" type="radio" data-ignite-amount="50.00" data-fv-field="donationAmtToggle2"
data-sli-widget="_ignxSBFaZHZk"><label class="sli-recurringAmountLabel sli-amount-label sli-small sli-push" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurringAmt_50_label"
for="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurringAmt_50">$50</label></li>
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurringAmt_75" type="radio" data-ignite-amount="75.00" data-fv-field="donationAmtToggle2"
data-sli-widget="_ignxSBFaZHZk"><label class="sli-recurringAmountLabel sli-amount-label sli-small sli-push" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurringAmt_75_label"
for="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurringAmt_75">$75</label></li>
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurringAmt_100" type="radio" data-ignite-amount="100.00" data-fv-field="donationAmtToggle2"
data-sli-widget="_ignxSBFaZHZk"><label class="sli-recurringAmountLabel sli-amount-label sli-small sli-push" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurringAmt_100_label"
for="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurringAmt_100">$100</label></li>
<li style=" display: block;"><input class="sli-recurringAmountRadio sli-recurringCustomAmount" name="donationAmtToggle2Other" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurringAmt_custom_radio" type="radio"
aria-label="recurring donation custom amount" data-sli-widget="_ignxSBFaZHZk">
<div class="sli-input-group"> <label class="sli-recurringAmountLabel sli-amount-label sli-customAmount sli-input-group-label sli-small sli-push" id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurringAmt_custom_label"
for="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurringAmt_custom" autocomplete="off">$</label> <input class="sli-recurringAmountInput sli-customAmount sli-input sli-input-group-field" size="5"
id="id_229d6cce-aef6-41da-bd6b-916d7c576ff2_PffRHuaSDa_recurringAmt_custom" type="text" placeholder="Other" name="customRecurringAmount" data-fv-row=".sli-recurringDonation" data-fv-err-container=".sli-recurringDonationError"
data-fv-numeric="true" data-fv-numeric-message="Please enter a dollar amount" data-fv-notempty="true" data-fv-notempty-message="An amount is required" data-fv-greaterthan="true" data-fv-greaterthan-inclusive="false"
data-fv-greaterthan-value="0.0" data-fv-greaterthan-message="Please enter a positive amount" autocomplete="off" data-fv-field="customRecurringAmount"> </div>
</li>
</ul>
<div class="sli-recurringDonationError sli-field-error"><small class="sli-field-error" data-fv-validator="recurringAmount" data-fv-for="donationAmtToggle2" data-fv-result="NOT_VALIDATED" style="display: none;">Please select a donation
amount, or enter your own amount</small><small class="sli-field-error" data-fv-validator="greaterThan" data-fv-for="customRecurringAmount" data-fv-result="NOT_VALIDATED" style="display: none;">Please enter a positive
amount</small><small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="customRecurringAmount" data-fv-result="NOT_VALIDATED" style="display: none;">An amount is required</small><small class="sli-field-error"
data-fv-validator="numeric" data-fv-for="customRecurringAmount" data-fv-result="NOT_VALIDATED" style="display: none;">Please enter a dollar amount</small></div>
</div>
</div>
</div>
</div>
</div>
<div class="sli-row" id="id_8d56b2c5-2931-4964-89b9-b86dcd8c6f56">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_a57c7fb8-9507-48bf-9934-f1f6b7198443">
<div class="sli-element sli-text" id="id_f6ddb663-bef3-403a-9edd-d04a988ba78a">
<div id="id_f6ddb663-bef3-403a-9edd-d04a988ba78a_inner">
<p> <span style="font-size:18px"><strong>Payment Details</strong></span> </p>
</div>
</div>
<div class="sli-donation-paymentblock sli-element" id="id_8ef8129f-bea4-4a4a-ae3a-347f4c7d807a">
<div class="sli-paymentType" id="id_8ef8129f-bea4-4a4a-ae3a-347f4c7d807a_paymentType" style="display: block;">
<div class="sli-ccType sli-label" for="payment_type"> Payment Type: </div>
<div style="display:inline-block;"> <input name="payment_type" type="radio" value="CREDIT_CARD" checked="checked" id="gEJHDbScci"> <label class="sli-label" for="gEJHDbScci">Credit Card</label> </div>
<div style="display:inline-block;"> <input name="payment_type" sli-payment-type="ACH" style="" type="radio" value="ACH" id="zyNgXHxWIc"> <label class="sli-label" style="" sli-payment-type="ACH" for="zyNgXHxWIc">eCheck</label> </div>
<div style="display:inline-block;"> <input name="payment_type" sli-payment-type="PAYPAL" style="" type="radio" value="PAYPAL" id="kmtTvlVJcW"> <label class="sli-label" style="" sli-payment-type="PAYPAL" for="kmtTvlVJcW">PayPal</label>
</div>
</div>
<div id="id_8ef8129f-bea4-4a4a-ae3a-347f4c7d807a_echeck_wepay" data-ignite-echeck-wepay="ignite-echeck-wepay"> <label class="sli-ccLabel sli-label" for="QjHyxIWQPp">Bank Account*</label>
<div class="sli-row">
<div class="sli-columns sli-medium-4 sli-large-4 sli-end sli-form-field"></div> <input class="sli-ccInput sli-input" type="text" id="QjHyxIWQPp" data-fv-field="wepay_bank" data-fv-notempty-message="Bank Account is required"
readonly="readonly" required="required" name="wepay_bank">
<div class="sli-columns sli-large-8 sli-medium-8"> <input class="sli-button" id="id_8ef8129f-bea4-4a4a-ae3a-347f4c7d807a_bankSelect" type="button" value="Select a Bank Account" name="bank-popup"> <small
class="sli-field-error sli-wepay-error" style="display: none;"></small> </div> <small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="wepay_bank" data-fv-result="NOT_VALIDATED" style="display: none;">Bank Account
is required</small>
</div>
</div>
<div id="id_8ef8129f-bea4-4a4a-ae3a-347f4c7d807a_echeck" data-ignite-echeck="ignite-echeck">
<div class="sli-row">
<div class="sli-columns sli-medium-8 sli-large-8 sli-small-12 sli-end sli-form-field"> <label class="sli-ccLabel sli-label" for="HceBEpWGbq">Name on Account*</label> <input class="sli-ccInput sli-input" type="text" name="holder_name"
id="HceBEpWGbq" required="required" data-fv-notempty="true" data-fv-notemtpy-message="Please enter the holder name" pattern="^.+\s+.*$" data-fv-regexp-message="Holder name must have at least 2 parts" data-fv-field="holder_name">
<small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="holder_name" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small><small class="sli-field-error" data-fv-validator="regexp"
data-fv-for="holder_name" data-fv-result="NOT_VALIDATED" style="display: none;">Holder name must have at least 2 parts</small></div>
</div>
<div class="sli-row">
<div class="sli-columns sli-large-8 sli-medium-8 sli-form-field"> <label class="sli-ccLabel sli-label" for="oGdQGmzDlQ">Bank Routing Number*</label> <input class="sli-ccInput sli-input" type="text" name="bank_routing" id="oGdQGmzDlQ"
required="required" maxlength="9" dava-fv-field="bank_routing" data-fv-notempty="true" data-fv-notemtpy-message="Bank Routing Number is required" data-fv-stringlength="true" data-fv-stringlength-min="9"
data-fv-stringlength-max="9" data-fv-stringlength-message="Bank Routing Number must be 9 characters long" data-fv-digits="true" data-fv-digits-message="Please enter only digits" data-fv-field="bank_routing"> <small
class="sli-field-error" data-fv-validator="digits" data-fv-for="bank_routing" data-fv-result="NOT_VALIDATED" style="display: none;">Please enter only digits</small><small class="sli-field-error" data-fv-validator="notEmpty"
data-fv-for="bank_routing" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small><small class="sli-field-error" data-fv-validator="stringLength" data-fv-for="bank_routing"
data-fv-result="NOT_VALIDATED" style="display: none;">Bank Routing Number must be 9 characters long</small></div>
</div>
<div class="sli-row">
<div class="sli-columns sli-large-8 sli-medium-8 sli-form-field"> <label class="sli-ccLabel sli-label" for="QGVgIfoMBf">Bank Account Number*</label> <input class="sli-bankAccount sli-ccInput sli-input" type="text" name="bank_account"
id="QGVgIfoMBf" required="required" maxlength="17" dava-fv-field="bank_account" data-fv-notempty="true" data-fv-notemtpy-message="Bank Account Number is required" data-fv-stringlength="true" data-fv-stringlength-min="4"
data-fv-stringlength-max="17" data-fv-stringlength-message="Bank Account Number must be from 4 to 17 characters long" data-fv-digits="true" data-fv-digits-message="Please enter only digits" data-fv-field="bank_account"> <small
class="sli-field-error" data-fv-validator="digits" data-fv-for="bank_account" data-fv-result="NOT_VALIDATED" style="display: none;">Please enter only digits</small><small class="sli-field-error" data-fv-validator="notEmpty"
data-fv-for="bank_account" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small><small class="sli-field-error" data-fv-validator="stringLength" data-fv-for="bank_account"
data-fv-result="NOT_VALIDATED" style="display: none;">Bank Account Number must be from 4 to 17 characters long</small></div>
</div>
</div>
<div id="id_8ef8129f-bea4-4a4a-ae3a-347f4c7d807a_cc" data-ignite-cc="ignite-cc">
<ul class="sli-cards">
<li class="sli-visa off" style=""></li>
<li class="sli-mastercard off" style=""></li>
<li class="sli-discover off" style=""></li>
<li class="sli-amex off" style=""></li>
</ul>
<div class="sli-row">
<div class="sli-columns sli-large-8 sli-medium-8 sli-form-field"> <label class="sli-ccLabel sli-label" for="KsrLCBeVeX">Card Number*</label> <input class="sli-ccInput sli-input" name="card_number" id="KsrLCBeVeX" type="text"
required="required" data-fv-notempty-message="A credit card number is required" maxlength="16" autocomplete="off" data-fv-creditcard="true" data-fv-creditcard-message="Please enter a valid credit card number"
data-fv-field="card_number"> <small class="sli-field-error" data-fv-validator="creditCard" data-fv-for="card_number" data-fv-result="NOT_VALIDATED" style="display: none;">Please enter a valid credit card number</small><small
class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="card_number" data-fv-result="NOT_VALIDATED" style="display: none;">A credit card number is required</small><small class="sli-field-error"
data-fv-validator="stringLength" data-fv-for="card_number" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small></div>
<div class="sli-columns sli-large-4 sli-medium-4 sli-end sli-form-field"> <label class="sli-ccExpCcvLabel sli-label" for="zcrxGoSpGJ">Security Code*</label> <input class="sli-ccExpCcvInput sli-input" name="cvv" id="zcrxGoSpGJ"
type="text" required="required" data-fv-notempty-message="CVV/CCV is required" maxlength="4" size="4" autocomplete="off" data-fv-cvv="true" data-fv-cvv_ccfield="card_number" data-dv-cvv-message="Your CVV is invalid"
data-fv-field="cvv"> <small class="sli-field-error" data-fv-validator="cvv" data-fv-for="cvv" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small><small class="sli-field-error"
data-fv-validator="notEmpty" data-fv-for="cvv" data-fv-result="NOT_VALIDATED" style="display: none;">CVV/CCV is required</small><small class="sli-field-error" data-fv-validator="stringLength" data-fv-for="cvv"
data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small></div>
</div>
<div class="sli-row">
<div class="sli-columns sli-large-6 sli-medium-6 sli-form-field"> <label class="sli-ccExpMonthLabel sli-label" for="rkXrHIPuoN">Expiration Month*</label> <select class="sli-ccInput sli-input" name="expiry_month" id="rkXrHIPuoN"
required="required" data-fv-notempty-message="Month is required" style="display: block;" data-fv-field="expiry_month">
<option value="" selected="selected">MM</option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select> <small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="expiry_month" data-fv-result="NOT_VALIDATED" style="display: none;">Month is required</small></div>
<div class="sli-columns sli-large-6 sli-medium-6 sli-end sli-form-field"> <label class="sli-ccExpMonthLabel sli-label" for="qhQwbZwnxM">Expiration Year*</label> <select class="sli-ccInput sli-input" name="expiry_year" id="qhQwbZwnxM"
required="required" data-fv-notempty-message="Year is required" style="display: block;" data-fv-field="expiry_year">
<option value="" selected="">YYYY</option>
<option value="23">2023</option>
<option value="24">2024</option>
<option value="25">2025</option>
<option value="26">2026</option>
<option value="27">2027</option>
<option value="28">2028</option>
<option value="29">2029</option>
<option value="30">2030</option>
<option value="31">2031</option>
<option value="32">2032</option>
<option value="33">2033</option>
<option value="34">2034</option>
<option value="35">2035</option>
<option value="36">2036</option>
<option value="37">2037</option>
<option value="38">2038</option>
<option value="39">2039</option>
<option value="40">2040</option>
<option value="41">2041</option>
<option value="42">2042</option>
</select> <small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="expiry_year" data-fv-result="NOT_VALIDATED" style="display: none;">Year is required</small></div>
</div>
<div class="sli-row">
<div class="sli-columns sli-large-12 sli-small-12 sli-end sli-form-field"> <label class="sli-ccNameLabel sli-label" for="SyLazxaFbY">Name on Card*</label> <input class="sli-ccNameInput sli-input" name="name_on_card" id="SyLazxaFbY"
type="text" autocomplete="off" required="required" data-fv-callback="true" data-fv-callback-callback="validateCCName" data-fv-field="name_on_card"> <small class="sli-field-error" data-fv-validator="callback"
data-fv-for="name_on_card" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small><small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="name_on_card" data-fv-result="NOT_VALIDATED"
style="display: none;">This value is not valid</small></div>
</div>
</div>
</div>
</div>
</div>
<div class="sli-row" id="id_37ef75ad-6080-4bdb-a2c2-8cc7d0e29931">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_4b8ff106-5f18-4e5d-a021-be784708eb11">
<div class="sli-element sli-text" id="id_70f12eb2-94cc-42db-adb0-fe6d079e4a87">
<div id="id_70f12eb2-94cc-42db-adb0-fe6d079e4a87_inner">
<p> <strong><span style="font-size:18px">Your Information</span></strong> </p>
</div>
</div>
</div>
</div>
<div class="sli-row" id="id_2b56bbff-208d-43f6-8143-800529522e9a">
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_1ed26fcd-3565-4018-9316-310204fba732">
<div class="sli-field-person-firstname sli-form-field sli-element" data-ignite-field-id="5d5a2165-f19e-4371-851b-183a6b92402b" id="id_33b8cc25-d7b3-4d69-b96c-ce123c7d9eb7"> <label class="sli-required-true sli-label"
for="id_33b8cc25-d7b3-4d69-b96c-ce123c7d9eb7_input" id="id_33b8cc25-d7b3-4d69-b96c-ce123c7d9eb7_label">First Name*</label> <input class="sli-input sli-input-person-firstname" type="text"
data-ignite-field-id="5d5a2165-f19e-4371-851b-183a6b92402b" name="field-person-firstname" maxlength="36" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true"
data-fv-stringlengthmessage="Please limit your input to at most 36 characters." id="id_33b8cc25-d7b3-4d69-b96c-ce123c7d9eb7_input" salsa-reference-name="person-firstname" data-fv-field="field-person-firstname"> <small
class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="field-person-firstname" data-fv-result="NOT_VALIDATED" style="display: none;">This field requires a value</small><small class="sli-field-error"
data-fv-validator="stringLength" data-fv-for="field-person-firstname" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small></div>
</div>
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_a95e2af8-fa1f-4cc8-81aa-518410a43f55">
<div class="sli-field-person-lastname sli-form-field sli-element" data-ignite-field-id="8d21a878-287a-491f-a362-b8ee2aa71819" id="id_66a40481-acd5-4358-a1c3-11fba940ba0c"> <label class="sli-required-true sli-label"
for="id_66a40481-acd5-4358-a1c3-11fba940ba0c_input" id="id_66a40481-acd5-4358-a1c3-11fba940ba0c_label">Last Name*</label> <input class="sli-input sli-input-person-lastname" type="text"
data-ignite-field-id="8d21a878-287a-491f-a362-b8ee2aa71819" name="field-person-lastname" maxlength="100" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true"
data-fv-stringlengthmessage="Please limit your input to at most 100 characters." id="id_66a40481-acd5-4358-a1c3-11fba940ba0c_input" salsa-reference-name="person-lastname" data-fv-field="field-person-lastname"> <small
class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="field-person-lastname" data-fv-result="NOT_VALIDATED" style="display: none;">This field requires a value</small><small class="sli-field-error"
data-fv-validator="stringLength" data-fv-for="field-person-lastname" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small></div>
</div>
</div>
<div class="sli-row" id="id_df411b9b-f996-434a-a784-9a7d4b3b4df8">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_dd360d9f-55c5-4238-a9cc-3a7772667fcf">
<div class="sli-field-address-line1 sli-form-field sli-element" data-ignite-field-id="f775c79a-df41-43fb-96de-ee2360254689" id="id_71416584-c47a-4440-b808-0394cf70a9a8"> <label class="sli-required-true sli-label"
for="id_71416584-c47a-4440-b808-0394cf70a9a8_input" id="id_71416584-c47a-4440-b808-0394cf70a9a8_label">Address, line 1*</label> <input class="sli-input sli-input-address-line1" type="text"
data-ignite-field-id="f775c79a-df41-43fb-96de-ee2360254689" name="field-address-line1" maxlength="128" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true"
data-fv-stringlengthmessage="Please limit your input to at most 128 characters." id="id_71416584-c47a-4440-b808-0394cf70a9a8_input" salsa-reference-name="address-line1" data-fv-field="field-address-line1"> <small class="sli-field-error"
data-fv-validator="notEmpty" data-fv-for="field-address-line1" data-fv-result="NOT_VALIDATED" style="display: none;">This field requires a value</small><small class="sli-field-error" data-fv-validator="stringLength"
data-fv-for="field-address-line1" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small></div>
<div class="sli-field-address-line2 sli-form-field sli-element" data-ignite-field-id="1ddcfe7f-7201-4a70-aa73-f1c93b4ca5a3" id="id_7a73c8cd-c7b9-49af-9de4-5fe423416146"> <label class="sli-required-false sli-label"
for="id_7a73c8cd-c7b9-49af-9de4-5fe423416146_input" id="id_7a73c8cd-c7b9-49af-9de4-5fe423416146_label">Address, line 2</label> <input class="sli-input sli-input-address-line2" type="text"
data-ignite-field-id="1ddcfe7f-7201-4a70-aa73-f1c93b4ca5a3" name="field-address-line2" maxlength="128" data-fv-stringlength="true" data-fv-stringlengthmessage="Please limit your input to at most 128 characters."
id="id_7a73c8cd-c7b9-49af-9de4-5fe423416146_input" salsa-reference-name="address-line2" data-fv-field="field-address-line2"> <small class="sli-field-error" data-fv-validator="stringLength" data-fv-for="field-address-line2"
data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small></div>
</div>
</div>
<div class="sli-row" id="id_a8989a78-9309-4d19-874d-ea2d759439c0">
<div class="sli-large-4 sli-medium-4 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_ffb406c3-2816-416b-8b8a-52b87b36a95f">
<div class="sli-field-address-city sli-form-field sli-element" data-ignite-field-id="a102d60f-f8ab-47eb-8ee0-864cfa1fc5b2" id="id_316ef758-f43e-4cb6-8d05-4731e69a9ab0"> <label class="sli-required-true sli-label"
for="id_316ef758-f43e-4cb6-8d05-4731e69a9ab0_input" id="id_316ef758-f43e-4cb6-8d05-4731e69a9ab0_label">City*</label> <input class="sli-input sli-input-address-city" type="text" data-ignite-field-id="a102d60f-f8ab-47eb-8ee0-864cfa1fc5b2"
name="field-address-city" maxlength="64" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true"
data-fv-stringlengthmessage="Please limit your input to at most 64 characters." id="id_316ef758-f43e-4cb6-8d05-4731e69a9ab0_input" salsa-reference-name="address-city" data-fv-field="field-address-city"> <small class="sli-field-error"
data-fv-validator="notEmpty" data-fv-for="field-address-city" data-fv-result="NOT_VALIDATED" style="display: none;">This field requires a value</small><small class="sli-field-error" data-fv-validator="stringLength"
data-fv-for="field-address-city" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small></div>
</div>
<div class="sli-large-4 sli-medium-4 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_7c647252-a5c5-4d18-90d2-4756ac275478">
<div class="sli-field-address-state sli-form-field sli-element" data-ignite-field-id="3f8b9098-ff2d-4384-bb95-425f113028c0" id="id_480d9b1d-6569-4e1f-a8ee-ead10abf72e3"> <label class="sli-required-true sli-label"
for="id_480d9b1d-6569-4e1f-a8ee-ead10abf72e3_input" id="id_480d9b1d-6569-4e1f-a8ee-ead10abf72e3_label">State*</label> <select class="sli-select-address-state sli-input" name="field-address-state"
data-ignite-field-id="3f8b9098-ff2d-4384-bb95-425f113028c0" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" id="id_480d9b1d-6569-4e1f-a8ee-ead10abf72e3_input"
salsa-reference-name="address-state" data-fv-field="field-address-state">
<option value="" selected="selected"> Choose one...</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AS">American Samoa</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="AA">Armed Forces America</option>
<option value="AE">Armed Forces Europe</option>
<option value="AP">Armed Forces Pacific</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="GU">Guam</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="MP">Northern Mariana Islands</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VI">Virgin Islands</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select> <small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="field-address-state" data-fv-result="NOT_VALIDATED" style="display: none;">This field requires a value</small></div>
</div>
<div class="sli-large-4 sli-medium-4 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_5200e0e2-81c5-4990-a44e-b56e19ecf21f">
<div class="sli-field-address-zip sli-form-field sli-element" data-ignite-field-id="44e5ad15-1fdd-4ba8-bf38-f5cbaad023c2" id="id_22c4116c-bf8c-4292-b565-2a50cb98374f"> <label class="sli-required-true sli-label"
for="id_22c4116c-bf8c-4292-b565-2a50cb98374f_input" id="id_22c4116c-bf8c-4292-b565-2a50cb98374f_label">Zip Code*</label> <input class="sli-input sli-input-address-zip" type="text"
data-ignite-field-id="44e5ad15-1fdd-4ba8-bf38-f5cbaad023c2" name="field-address-zip" maxlength="20" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true"
data-fv-stringlengthmessage="Please limit your input to at most 20 characters." data-fv-zipcode="true" data-fv-zipcode-priority="1" data-fv-zipcode-country="US" data-fv-zipcode-message="This value is not valid as a %s postal code"
data-fv-regexp="true" data-fv-regexp-priority="2" data-fv-regexp-regexp="^(\d{5}|\d{5}-\d{4})?$" data-fv-regexp-message="Zip Code must be formatted as: "55555" or "55555-5555""
id="id_22c4116c-bf8c-4292-b565-2a50cb98374f_input" salsa-reference-name="address-zip" data-fv-field="field-address-zip"> <small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="field-address-zip"
data-fv-result="NOT_VALIDATED" style="display: none;">This field requires a value</small><small class="sli-field-error" data-fv-validator="regexp" data-fv-for="field-address-zip" data-fv-result="NOT_VALIDATED" style="display: none;">Zip
Code must be formatted as: "55555" or "55555-5555"</small><small class="sli-field-error" data-fv-validator="stringLength" data-fv-for="field-address-zip" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not
valid</small><small class="sli-field-error" data-fv-validator="zipCode" data-fv-for="field-address-zip" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid as a %s postal code</small></div>
</div>
</div>
<div class="sli-row" id="id_0959c7ed-bad8-4b8a-ae23-fc18838ee20d">
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_5bf67922-dd77-4ea3-af5c-8aaa17bc8b7e">
<div class="sli-field-contact-email sli-form-field sli-element" data-ignite-field-id="2851b463-606f-40c8-bb3d-d31f399e6896" id="id_a80626d7-49aa-478f-b5e9-cf2195b87aca"> <label class="sli-required-true sli-label"
for="id_a80626d7-49aa-478f-b5e9-cf2195b87aca_input" id="id_a80626d7-49aa-478f-b5e9-cf2195b87aca_label">Email Address*</label> <input class="sli-input sli-input-contact-email" type="email"
data-ignite-field-id="2851b463-606f-40c8-bb3d-d31f399e6896" name="field-contact-email" maxlength="128" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true"
data-fv-stringlengthmessage="Please limit your input to at most 128 characters." data-fv-regexp="true" data-fv-regexp-regexp="^[^@\s]+@([^@\s]+\.)+[^@\s]+$" data-fv-regexp-message="Please enter a valid email address"
id="id_a80626d7-49aa-478f-b5e9-cf2195b87aca_input" salsa-reference-name="contact-email" data-fv-field="field-contact-email"> <small class="sli-field-error" data-fv-validator="emailAddress" data-fv-for="field-contact-email"
data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small><small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="field-contact-email" data-fv-result="NOT_VALIDATED"
style="display: none;">This field requires a value</small><small class="sli-field-error" data-fv-validator="regexp" data-fv-for="field-contact-email" data-fv-result="NOT_VALIDATED" style="display: none;">Please enter a valid email
address</small><small class="sli-field-error" data-fv-validator="stringLength" data-fv-for="field-contact-email" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small></div>
<div class="sli-element sli-spacer" id="id_40de6623-bfaa-47ed-8293-31b628d74501"> </div>
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<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_1d6a3935-cfff-4396-9eca-649152be25e2">
<div class="sli-field-person-home_phone sli-form-field sli-element" data-ignite-field-id="6e201e0b-8208-453f-b393-a5f0d9059726" id="id_3fed2075-c56d-4497-807f-ef2c7fcfb36b"> <label class="sli-required-false sli-label"
for="id_3fed2075-c56d-4497-807f-ef2c7fcfb36b_input" id="id_3fed2075-c56d-4497-807f-ef2c7fcfb36b_label">Phone</label> <input class="sli-input sli-input-person-home_phone" type="text"
data-ignite-field-id="6e201e0b-8208-453f-b393-a5f0d9059726" name="field-person-home_phone" placeholder="555-555-5555" maxlength="12" data-fv-stringlength="true"
data-fv-stringlengthmessage="Please limit your input to at most 128 characters." id="id_3fed2075-c56d-4497-807f-ef2c7fcfb36b_input" salsa-reference-name="person-home_phone" data-fv-field="field-person-home_phone"> <small
class="sli-field-error" data-fv-validator="stringLength" data-fv-for="field-person-home_phone" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small></div>
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<div class="sli-row" id="id_0947ab3d-d672-4ddc-b76c-50401584b985">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_fc9fa8e0-6d4d-4c89-b820-9813c6be3e10">
<div class="sli-donationsummary-dedication sli-columns sli-large-12 sli-select-radio sli-element " id="id_143bce4a-1138-4023-9dfc-ae14000e8564_dedication" salsa-reference-name="dedication_type">
<div> <label class="sli-label" for="id_143bce4a-1138-4023-9dfc-ae14000e8564_dedication">Donation Dedication</label>
<ul>
<li><input name="dedicationType" id="id_143bce4a-1138-4023-9dfc-ae14000e8564_NONE" value="NONE" type="radio" checked="checked">None</li>
<li><input name="dedicationType" id="id_143bce4a-1138-4023-9dfc-ae14000e8564_InHonorOf" value="InHonorOf" type="radio">In Honor Of</li>
<li><input name="dedicationType" id="id_143bce4a-1138-4023-9dfc-ae14000e8564_InMemoryOf" value="InMemoryOf" type="radio">In Memory Of</li>
</ul> <input class="sli-input" type="text" disabled="" name="dedication" data-fv-row=".sli-donationsummary-dedication" data-fv-nohtml="true" data-fv-nohtml-message="Your input is invalid" maxlength="250" data-fv-stringlength="true"
data-fv-stringlength-message="Please limit your input to less than 250 characters" data-fv-notempty="true" data-fv-notempty-message="Please provide a dedication" data-ignite-field-id="6a921941-0a96-474a-9c1d-f51aa791811b"
salsa-reference-name="donationsummary-dedication" data-fv-field="dedication">
<div class="sli-dedicationError"></div>
<style ignite-allow-style="ignite-allow-style">
#id_143bce4a-1138-4023-9dfc-ae14000e8564_dedication li {
display: inline;
padding: 8px;
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#id_143bce4a-1138-4023-9dfc-ae14000e8564_dedication input[type=radio] {
margin-right: 4px;
}
#id_143bce4a-1138-4023-9dfc-ae14000e8564_dedication ul {
margin: 4px;
padding: 0px;
}
@media screen and (max-width:640px) {
#id_143bce4a-1138-4023-9dfc-ae14000e8564_dedication li {
display: block;
padding: 2px 0 0 0;
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}
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</div> <small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="dedication" data-fv-result="NOT_VALIDATED" style="display: none;">Please provide a dedication</small><small class="sli-field-error"
data-fv-validator="stringLength" data-fv-for="dedication" data-fv-result="NOT_VALIDATED" style="display: none;">Please limit your input to less than 250 characters</small><small class="sli-field-error" data-fv-validator="nohtml"
data-fv-for="dedication" data-fv-result="NOT_VALIDATED" style="display: none;">Your input is invalid</small>
</div>
<div class="sli-row" id="id_ea5876cb-2f57-4097-ae46-3937e3f05e9d">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_a1baf861-ff2c-4669-86cb-50c1189f2e12">
<div class="sli-donationsummary-notify sli-element sli-form-field sli-columns sli-large-12 " id="id_82277612-3e11-4e2a-bb43-6dc544457964">
<div> <label class="sli-label" for="id_82277612-3e11-4e2a-bb43-6dc544457964_notify_input">Please notify the following person(s) that a donation has been made.</label> <input class="sli-input"
id="id_82277612-3e11-4e2a-bb43-6dc544457964_notify_input" type="text" name="field-donationsummary-notify" data-ignite-field-id="4abbf015-7829-4bda-a574-94ac97994229" data-fv-nohtml="true"
data-fv-nohtml-message="Your input is invalid" maxlength="250" data-fv-stringlength="true" data-fv-stringlength-message="Please limit your input to less than 250 characters" salsa-reference-name="donationsummary-notify"
data-fv-field="field-donationsummary-notify"> </div> <small class="sli-field-error" data-fv-validator="stringLength" data-fv-for="field-donationsummary-notify" data-fv-result="NOT_VALIDATED" style="display: none;">Please limit
your input to less than 250 characters</small><small class="sli-field-error" data-fv-validator="nohtml" data-fv-for="field-donationsummary-notify" data-fv-result="NOT_VALIDATED" style="display: none;">Your input is invalid</small>
</div>
</div>
</div>
</div>
</div>
<div class="sli-row" id="id_543c6277-52a1-4382-8faf-289a08b6ab07">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_14540ea1-aa84-41c4-a1e5-34d9f6047363">
<div id="id_a7cd1870-6388-474d-8ef5-1fe93bb51211"> <label class="sli-label" for="dd-company-name-input">Let's see if your company will match your gift. Look up your company name here.</label>
<div id="dd-company-name-input" data-doublethedonation-widget-id="G__4">
<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="combobox" aria-expanded="false"
name="doublethedonation_company_name_input" autocomplete="new-password" type="text" id="dd-input" class="dtd-search-input form-control BBFormTextbox" style="width: 100%;" placeholder="Search for company..."
aria-label="Search for company...">
</div>
</div>
</div>
</div>
<div class="sli-field-af385b76-bae7-4fba-98a3-ebea45bf57fa sli-form-field sli-element" data-ignite-field-id="af385b76-bae7-4fba-98a3-ebea45bf57fa" id="id_a75014e6-ba3c-4bd0-8ada-c18cec4828dc"> <label class="sli-required-false sli-label"
for="id_a75014e6-ba3c-4bd0-8ada-c18cec4828dc_input" id="id_a75014e6-ba3c-4bd0-8ada-c18cec4828dc_label">Direct my donation to the Remarkable US Disability Tech Accelerator.</label>
<div class="sli-select-radio sli-orientation-horizontal" id="id_a75014e6-ba3c-4bd0-8ada-c18cec4828dc_input" salsa-reference-name="scf_remarkable_us_disability_tech_accelerator"> <label class="sli-label"
for="id_a75014e6-ba3c-4bd0-8ada-c18cec4828dc_Yes"><input data-ignite-field-id="af385b76-bae7-4fba-98a3-ebea45bf57fa" id="id_a75014e6-ba3c-4bd0-8ada-c18cec4828dc_Yes" type="radio" name="field-af385b76-bae7-4fba-98a3-ebea45bf57fa"
value="true"> Yes</label> <label class="sli-label" for="id_a75014e6-ba3c-4bd0-8ada-c18cec4828dc_No"><input data-ignite-field-id="af385b76-bae7-4fba-98a3-ebea45bf57fa" id="id_a75014e6-ba3c-4bd0-8ada-c18cec4828dc_No" type="radio"
name="field-af385b76-bae7-4fba-98a3-ebea45bf57fa" value="false" checked="checked"> No</label> </div>
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<div class="sli-field-19740e6b-fbc5-4907-9862-4b0bc9b5c111 sli-form-field sli-element" data-ignite-field-id="19740e6b-fbc5-4907-9862-4b0bc9b5c111" id="id_9a250bff-e20f-49bb-b9dd-214351edbace"> <label class="sli-required-false sli-label"
for="id_9a250bff-e20f-49bb-b9dd-214351edbace_input" id="id_9a250bff-e20f-49bb-b9dd-214351edbace_label">What moved you to give today?</label> <select class="sli-select-19740e6b-fbc5-4907-9862-4b0bc9b5c111 sli-input"
name="field-19740e6b-fbc5-4907-9862-4b0bc9b5c111" data-ignite-field-id="19740e6b-fbc5-4907-9862-4b0bc9b5c111" id="id_9a250bff-e20f-49bb-b9dd-214351edbace_input" salsa-reference-name="scf_what_moved_you_to_give_today_">
<option value="I want to support Remarkable US and disability tech.">I want to support Remarkable US and disability tech.</option>
<option value="I have cerebral palsy.">I have cerebral palsy.</option>
<option value="I support cerebral palsy research.">I support cerebral palsy research.</option>
<option value="Make a selection" selected="selected">Make a selection</option>
<option value="One of my friends or family members has cerebral palsy.">One of my friends or family members has cerebral palsy.</option>
</select> </div>
<div class="sli-contact-types sli-element " id="id_5e633899-0de1-43ea-a3f5-12f531846232" data-ignite-field-id="ContactOptIn"> <label class="sli-label"><input class="sli-input sli-contact-type Email" type="checkbox"
id="id_5e633899-0de1-43ea-a3f5-12f531846232_contact_types_input" checked="checked" name="contactOptIn" value="accepted" style="margin-right: 5px;" data-ignite-contact-value="Email" salsa-reference-name="contactoptincb"> I'd like
to receive CPARF updates.</label>
<div class="sli-contact-type"></div>
</div>
</div>
</div>
<div class="sli-row" id="id_cbc5956a-2826-490a-8ac0-624771632983">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_2e073f87-8c8d-423c-9228-3630db6ca9f5">
<div class="sli-element sli-button-element" id="id_71516ed4-9ca0-44f7-8bed-90e80385f831">
<a class="sli-button sli-push sli-large" track="true" data-ignite-submit-button="data-ignite-submit-button" style="font-family:'Arial Black', Gadget, sans-serif;background-color:rgb(39,78,19);border-radius:0px;border-style: solid;" tabindex="0" role="button">Donate Now</a>
<div class="sli-processing" style="display:none;"></div>
</div>
</div>
</div>
</div>
</div>
</form>Text Content
Loading.... DONATE ONLINE This is the fastest way to make an impact on cerebral palsy research and disability innovation. Make your gift online today to move Cerebral Palsy Alliance Research Foundation's work forward. Increase my donation amount to cover fees. Make this a monthly donation. * $25 * $50 * $100 * $200 * $500 * $ Please select a donation amount, or enter your own amountPlease enter a positive amountAn amount is requiredPlease enter a dollar amount Donation will repeat monthly. * $10 * $25 * $50 * $75 * $100 * $ Please select a donation amount, or enter your own amountPlease enter a positive amountAn amount is requiredPlease enter a dollar amount Payment Details Payment Type: Credit Card eCheck PayPal Bank Account* Bank Account is required Name on Account* This value is not validHolder name must have at least 2 parts Bank Routing Number* Please enter only digitsThis value is not validBank Routing Number must be 9 characters long Bank Account Number* Please enter only digitsThis value is not validBank Account Number must be from 4 to 17 characters long * * * * Card Number* Please enter a valid credit card numberA credit card number is requiredThis value is not valid Security Code* This value is not validCVV/CCV is requiredThis value is not valid Expiration Month* MM010203040506070809101112 Month is required Expiration Year* YYYY20232024202520262027202820292030203120322033203420352036203720382039204020412042 Year is required Name on Card* This value is not validThis value is not valid Your Information First Name* This field requires a valueThis value is not valid Last Name* This field requires a valueThis value is not valid Address, line 1* This field requires a valueThis value is not valid Address, line 2 This value is not valid City* This field requires a valueThis value is not valid State* Choose one...AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces AmericaArmed Forces EuropeArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUnited States Minor Outlying IslandsUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming This field requires a value Zip Code* This field requires a valueZip Code must be formatted as: "55555" or "55555-5555"This value is not validThis value is not valid as a %s postal code Email Address* This value is not validThis field requires a valuePlease enter a valid email addressThis value is not valid Phone This value is not valid Donation Dedication * None * In Honor Of * In Memory Of Please provide a dedicationPlease limit your input to less than 250 charactersYour input is invalid Please notify the following person(s) that a donation has been made. Please limit your input to less than 250 charactersYour input is invalid Let's see if your company will match your gift. Look up your company name here. Direct my donation to the Remarkable US Disability Tech Accelerator. Yes No What moved you to give today? I want to support Remarkable US and disability tech.I have cerebral palsy.I support cerebral palsy research.Make a selectionOne of my friends or family members has cerebral palsy. I'd like to receive CPARF updates. Donate Now Please review before submitting your payment. Item Charge Registrations $0.00 Purchases $0.00 Donation $0.00 Fees NONE Total No Charge THANK YOU FOR YOUR DONATION! DOES YOUR EMPLOYER MATCH CHARITABLE DONATIONS? Cerebral Palsy Alliance Research Foundation (CPARF) thanks you for checking to see if you can double your impact through your workplace. If your company matches donations, that means your gift will go twice as far to support cerebral palsy research and disability innovation. * In-depth chronic pain studies and the discovery of non-opioid treatment alternatives. * Exploring ethically sourced and engineered stem cells to repair brain damage. * Thought-to-speech technology that unlocks the ability to communicate for millions of people with CP and other disabilities like ALS and Parkinson’s Disease. With your generosity and our reach, we’ll make a difference for people living with CP — and for future generations as we work toward prevention and a cure. See if your employer will match your donation Let's Check All information provided by Double the Donation Spread the word! Facebook Twitter LinkedIn Email Questions? Contact info@cparf.org