secure.pva.org
Open in
urlscan Pro
151.101.1.91
Public Scan
URL:
https://secure.pva.org/
Submission: On November 28 via manual from US — Scanned from US
Submission: On November 28 via manual from US — Scanned from US
Form analysis 1 forms found in the DOM
POST /
<form class="webform-client-form form-layouts one-column fundraiser-donation-form full-address-processed tribute-validation-processed jquery-once-4-processed premium-required-processed donation-messages-processed jquery-once-7-processed"
enctype="multipart/form-data" action="/" method="post" id="webform-client-form-61" accept-charset="UTF-8" novalidate="novalidate">
<fieldset class="webform-component-fieldset form-wrapper" id="webform-component-donation">
<legend><span class="fieldset-legend">My Donation</span></legend>
<div class="fieldset-wrapper">
<div class="form-item webform-component webform-component-radios control-group" id="webform-component-donation--recurs-monthly">
<div id="edit-submitted-donation-recurs-monthly">
<div class="form-item form-type-radio form-item-submitted-donation-recurs-monthly control-group">
<input type="radio" id="edit-submitted-donation-recurs-monthly-1" name="submitted[donation][recurs_monthly]" value="NO_RECURR" placeholder=""> <label class="option" for="edit-submitted-donation-recurs-monthly-1">One-time </label>
</div>
<div class="form-item form-type-radio form-item-submitted-donation-recurs-monthly control-group">
<input type="radio" id="edit-submitted-donation-recurs-monthly-2" name="submitted[donation][recurs_monthly]" value="recurs" checked="checked" placeholder=""> <label class="option" for="edit-submitted-donation-recurs-monthly-2">Monthly
</label>
<div class="description"><img src="https://pva.gospringboard.com/files/pva/give-24-monthly.png" alt="Most give $24 monthly"></div>
</div>
</div>
</div>
<div class="form-item webform-component webform-component-radios control-group" id="webform-component-donation--recurring-amount">
<div id="edit-submitted-donation-recurring-amount" class="even">
<div class="form-item form-type-radio form-item-submitted-donation-recurring-amount control-group">
<input type="radio" id="edit-submitted-donation-recurring-amount-1" name="submitted[donation][recurring_amount]" value="19" placeholder=""> <label class="option" for="edit-submitted-donation-recurring-amount-1">$19 <span
class="form-required">*</span></label>
</div>
<div class="form-item form-type-radio form-item-submitted-donation-recurring-amount control-group">
<input type="radio" id="edit-submitted-donation-recurring-amount-2" name="submitted[donation][recurring_amount]" value="24" checked="checked" placeholder=""> <label class="option" for="edit-submitted-donation-recurring-amount-2">$24 <span
class="form-required">*</span></label>
</div>
<div class="form-item form-type-radio form-item-submitted-donation-recurring-amount control-group">
<input type="radio" id="edit-submitted-donation-recurring-amount-3" name="submitted[donation][recurring_amount]" value="30" placeholder=""> <label class="option" for="edit-submitted-donation-recurring-amount-3">$30 <span
class="form-required">*</span></label>
</div>
<div class="form-item form-type-radio form-item-submitted-donation-recurring-amount control-group">
<input type="radio" id="edit-submitted-donation-recurring-amount-4" name="submitted[donation][recurring_amount]" value="35" placeholder=""> <label class="option" for="edit-submitted-donation-recurring-amount-4">$35 <span
class="form-required">*</span></label>
</div>
<div class="form-item form-type-radio form-item-submitted-donation-recurring-amount control-group other">
<input type="radio" id="edit-submitted-donation-recurring-amount-5" name="submitted[donation][recurring_amount]" value="other" placeholder=""> <label class="option" for="edit-submitted-donation-recurring-amount-5">Other <span
class="form-required">*</span></label>
</div>
<div class="form-item webform-component webform-component-textfield control-group" id="webform-component-donation--recurring-other-amount">
<label for="edit-submitted-donation-recurring-other-amount">Other </label>
<div class="field-prefix">$</div><input class="input-medium form-text other-field" type="text" id="edit-submitted-donation-recurring-other-amount" name="submitted[donation][recurring_other_amount]" value="" size="10" maxlength="128"
placeholder="My Best Gift">
<div class="description">Minimum payment $5.00.</div>
</div>
</div>
</div>
<div class="form-item webform-component webform-component-radios control-group" id="webform-component-donation--amount" style="display: none;">
<div id="edit-submitted-donation-amount" class="even">
<div class="form-item form-type-radio form-item-submitted-donation-amount control-group">
<input type="radio" id="edit-submitted-donation-amount-1" name="submitted[donation][amount]" value="25" placeholder=""> <label class="option" for="edit-submitted-donation-amount-1">$25 </label>
</div>
<div class="form-item form-type-radio form-item-submitted-donation-amount control-group">
<input type="radio" id="edit-submitted-donation-amount-2" name="submitted[donation][amount]" value="50" placeholder=""> <label class="option" for="edit-submitted-donation-amount-2">$50 </label>
</div>
<div class="form-item form-type-radio form-item-submitted-donation-amount control-group">
<input type="radio" id="edit-submitted-donation-amount-3" name="submitted[donation][amount]" value="100" placeholder=""> <label class="option" for="edit-submitted-donation-amount-3">$100 </label>
</div>
<div class="form-item form-type-radio form-item-submitted-donation-amount control-group">
<input type="radio" id="edit-submitted-donation-amount-4" name="submitted[donation][amount]" value="250" checked="checked" placeholder=""> <label class="option" for="edit-submitted-donation-amount-4">$250 </label>
</div>
<div class="form-item form-type-radio form-item-submitted-donation-amount control-group other">
<input type="radio" id="edit-submitted-donation-amount-5" name="submitted[donation][amount]" value="other" placeholder=""> <label class="option" for="edit-submitted-donation-amount-5">Other </label>
</div>
<div class="form-item webform-component webform-component-textfield control-group" id="webform-component-donation--other-amount" style="display: none;">
<label for="edit-submitted-donation-other-amount">Other </label>
<div class="field-prefix">$</div><input class="input-medium form-text other-field" type="text" id="edit-submitted-donation-other-amount" name="submitted[donation][other_amount]" value="" size="10" maxlength="128"
placeholder="My Best Gift">
<div class="description">Minimum payment $5.00.</div>
</div>
</div>
</div>
</div>
<div class="form-item webform-component webform-component-checkboxes control-group" id="webform-component-donation--processing-fee">
<div id="edit-submitted-donation-processing-fee">
<div class="form-item form-type-checkbox form-item-submitted-donation-processing-fee-1 control-group">
<input type="checkbox" id="edit-submitted-donation-processing-fee-1" name="submitted[donation][processing_fee][1]" value="1" class="form-checkbox" placeholder=""> <label class="option" for="edit-submitted-donation-processing-fee-1">Add 3%
to my donation to cover credit card fees.</label>
<span data-toggle="popover" data-trigger="hover" class="fa fa-question-circle help-text popovers" data-placement="top"
data-content="Credit card companies deduct fees on every transaction. You can increase your impact by offsetting those fees." data-original-title="" title=""></span>
</div>
</div>
</div>
</fieldset>
<fieldset class="webform-component-fieldset form-wrapper" id="webform-component-tribute-information">
<div class="fieldset-wrapper">
<div class="form-item webform-component webform-component-checkboxes control-group" id="webform-component-tribute-information--tribute-memorial">
<div id="edit-submitted-tribute-information-tribute-memorial">
<div class="form-item form-type-checkbox form-item-submitted-tribute-information-tribute-memorial-Tribute control-group">
<input type="checkbox" id="edit-submitted-tribute-information-tribute-memorial-1" name="submitted[tribute_information][tribute_memorial][Tribute]" value="Tribute" class="form-checkbox" placeholder=""> <label class="option"
for="edit-submitted-tribute-information-tribute-memorial-1">Dedicate my donation in honor of or in memorial of someone. </label>
</div>
</div>
</div>
<fieldset class="webform-component-fieldset form-wrapper" id="webform-component-tribute-information--toggle-wrapper" style="display: none;">
<div class="fieldset-wrapper">
<div class="form-item webform-component webform-component-textfield control-group" id="webform-component-tribute-information--toggle-wrapper--honoree-first-name">
<input type="text" id="edit-submitted-tribute-information-toggle-wrapper-honoree-first-name" name="submitted[tribute_information][toggle_wrapper][honoree_first_name]" value="" size="60" maxlength="128" class="form-text"
placeholder="Honoree Name "><label for="edit-submitted-tribute-information-toggle-wrapper-honoree-first-name" class="replaced">Honoree Name </label>
</div>
<div class="form-item webform-component webform-component-select control-group" id="webform-component-tribute-information--toggle-wrapper--occasion">
<label for="edit-submitted-tribute-information-toggle-wrapper-occasion">Occasion </label>
<div class="select-wrapper"><select id="edit-submitted-tribute-information-toggle-wrapper-occasion" name="submitted[tribute_information][toggle_wrapper][occasion]" class="form-select" placeholder="">
<option value="" selected="selected">- None -</option>
<option value="honor">In honor of</option>
<option value="memorial">In memory of</option>
</select></div>
</div>
<div class="form-item webform-component webform-component-radios control-group" id="webform-component-tribute-information--toggle-wrapper--would-you-like-to-send-an-ecard">
<label for="edit-submitted-tribute-information-toggle-wrapper-would-you-like-to-send-an-ecard">Would you like to send an eCard? </label>
<div id="edit-submitted-tribute-information-toggle-wrapper-would-you-like-to-send-an-ecard">
<div class="form-item form-type-radio form-item-submitted-tribute-information-toggle-wrapper-would-you-like-to-send-an-ecard control-group">
<input type="radio" id="edit-submitted-tribute-information-toggle-wrapper-would-you-like-to-send-an-ecard-1" name="submitted[tribute_information][toggle_wrapper][would_you_like_to_send_an_ecard]" value="no" checked="checked"
placeholder=""> <label class="option" for="edit-submitted-tribute-information-toggle-wrapper-would-you-like-to-send-an-ecard-1">No </label>
</div>
<div class="form-item form-type-radio form-item-submitted-tribute-information-toggle-wrapper-would-you-like-to-send-an-ecard control-group">
<input type="radio" id="edit-submitted-tribute-information-toggle-wrapper-would-you-like-to-send-an-ecard-2" name="submitted[tribute_information][toggle_wrapper][would_you_like_to_send_an_ecard]" value="yes" placeholder=""> <label
class="option" for="edit-submitted-tribute-information-toggle-wrapper-would-you-like-to-send-an-ecard-2">Yes </label>
</div>
</div>
</div>
<fieldset class="webform-component-fieldset form-wrapper" id="webform-component-tribute-information--toggle-wrapper--ecard-fields" style="display: none;">
<div class="fieldset-wrapper">
<div class="form-item webform-component webform-component-textfield control-group" id="webform-component-tribute-information--toggle-wrapper--ecard-fields--recipient-first-name">
<input type="text" id="edit-submitted-tribute-information-toggle-wrapper-ecard-fields-recipient-first-name" name="submitted[tribute_information][toggle_wrapper][ecard_fields][recipient_first_name]" value="" size="60" maxlength="128"
class="form-text" placeholder="Recipient First Name "><label for="edit-submitted-tribute-information-toggle-wrapper-ecard-fields-recipient-first-name" class="replaced">Recipient First Name </label>
</div>
<div class="form-item webform-component webform-component-textfield control-group" id="webform-component-tribute-information--toggle-wrapper--ecard-fields--recipient-last-name">
<input type="text" id="edit-submitted-tribute-information-toggle-wrapper-ecard-fields-recipient-last-name" name="submitted[tribute_information][toggle_wrapper][ecard_fields][recipient_last_name]" value="" size="60" maxlength="128"
class="form-text" placeholder="Recipient Last Name "><label for="edit-submitted-tribute-information-toggle-wrapper-ecard-fields-recipient-last-name" class="replaced">Recipient Last Name </label>
</div>
<div class="form-item webform-component webform-component-email control-group" id="webform-component-tribute-information--toggle-wrapper--ecard-fields--recipient-e-mail-address">
<input class="email form-text form-email" type="email" id="edit-submitted-tribute-information-toggle-wrapper-ecard-fields-recipient-e-mail-address"
name="submitted[tribute_information][toggle_wrapper][ecard_fields][recipient_e_mail_address]" size="60" placeholder="Recipient e-mail address "><label
for="edit-submitted-tribute-information-toggle-wrapper-ecard-fields-recipient-e-mail-address" class="replaced">Recipient e-mail address </label>
</div>
<div class="form-item webform-component webform-component-textfield control-group" id="webform-component-tribute-information--toggle-wrapper--ecard-fields--ecard-subject">
<input type="text" id="edit-submitted-tribute-information-toggle-wrapper-ecard-fields-ecard-subject" name="submitted[tribute_information][toggle_wrapper][ecard_fields][ecard_subject]" value="" size="60" maxlength="128"
class="form-text" placeholder="eCard subject "><label for="edit-submitted-tribute-information-toggle-wrapper-ecard-fields-ecard-subject" class="replaced">eCard subject </label>
</div>
<div class="form-item webform-component webform-component-textarea control-group" id="webform-component-tribute-information--toggle-wrapper--ecard-fields--ecard-message">
<textarea id="edit-submitted-tribute-information-toggle-wrapper-ecard-fields-ecard-message" name="submitted[tribute_information][toggle_wrapper][ecard_fields][ecard_message]" cols="60" rows="5" class="form-textarea"
placeholder="eCard message "></textarea><label for="edit-submitted-tribute-information-toggle-wrapper-ecard-fields-ecard-message" class="replaced">eCard message </label>
</div>
</div>
</fieldset>
<div class="form-item webform-component webform-component-radios control-group" id="webform-component-tribute-information--toggle-wrapper--would-you-like-to-send-a-paper-card">
<label for="edit-submitted-tribute-information-toggle-wrapper-would-you-like-to-send-a-paper-card">Would you like to send a paper card? </label>
<div id="edit-submitted-tribute-information-toggle-wrapper-would-you-like-to-send-a-paper-card">
<div class="form-item form-type-radio form-item-submitted-tribute-information-toggle-wrapper-would-you-like-to-send-a-paper-card control-group">
<input type="radio" id="edit-submitted-tribute-information-toggle-wrapper-would-you-like-to-send-a-paper-card-1" name="submitted[tribute_information][toggle_wrapper][would_you_like_to_send_a_paper_card]" value="no" checked="checked"
placeholder=""> <label class="option" for="edit-submitted-tribute-information-toggle-wrapper-would-you-like-to-send-a-paper-card-1">No </label>
</div>
<div class="form-item form-type-radio form-item-submitted-tribute-information-toggle-wrapper-would-you-like-to-send-a-paper-card control-group">
<input type="radio" id="edit-submitted-tribute-information-toggle-wrapper-would-you-like-to-send-a-paper-card-2" name="submitted[tribute_information][toggle_wrapper][would_you_like_to_send_a_paper_card]" value="yes" placeholder="">
<label class="option" for="edit-submitted-tribute-information-toggle-wrapper-would-you-like-to-send-a-paper-card-2">Yes </label>
</div>
</div>
</div>
<fieldset class="webform-component-fieldset form-wrapper" id="webform-component-tribute-information--toggle-wrapper--paper-card-fields" style="display: none;">
<div class="fieldset-wrapper">
<div class="form-item webform-component webform-component-textfield control-group" id="webform-component-tribute-information--toggle-wrapper--paper-card-fields--shipping-first-name">
<input type="text" id="edit-submitted-tribute-information-toggle-wrapper-paper-card-fields-shipping-first-name" name="submitted[tribute_information][toggle_wrapper][paper_card_fields][shipping_first_name]" value="" size="60"
maxlength="128" class="form-text" placeholder="Shipping First Name "><label for="edit-submitted-tribute-information-toggle-wrapper-paper-card-fields-shipping-first-name" class="replaced">Shipping First Name </label>
</div>
<div class="form-item webform-component webform-component-textfield control-group" id="webform-component-tribute-information--toggle-wrapper--paper-card-fields--shipping-last-name">
<input type="text" id="edit-submitted-tribute-information-toggle-wrapper-paper-card-fields-shipping-last-name" name="submitted[tribute_information][toggle_wrapper][paper_card_fields][shipping_last_name]" value="" size="60"
maxlength="128" class="form-text" placeholder="Shipping Last Name "><label for="edit-submitted-tribute-information-toggle-wrapper-paper-card-fields-shipping-last-name" class="replaced">Shipping Last Name </label>
</div>
<div class="form-item webform-component webform-component-textfield control-group" id="webform-component-tribute-information--toggle-wrapper--paper-card-fields--shipping-address">
<input type="text" id="edit-submitted-tribute-information-toggle-wrapper-paper-card-fields-shipping-address" name="submitted[tribute_information][toggle_wrapper][paper_card_fields][shipping_address]" value="" size="60" maxlength="128"
class="form-text" placeholder="Shipping Address "><label for="edit-submitted-tribute-information-toggle-wrapper-paper-card-fields-shipping-address" class="replaced">Shipping Address </label>
</div>
<div class="form-item webform-component webform-component-textfield control-group" id="webform-component-tribute-information--toggle-wrapper--paper-card-fields--shipping-address-line-2">
<input type="text" id="edit-submitted-tribute-information-toggle-wrapper-paper-card-fields-shipping-address-line-2" name="submitted[tribute_information][toggle_wrapper][paper_card_fields][shipping_address_line_2]" value="" size="60"
maxlength="128" class="form-text" placeholder="Shipping Address Line 2 "><label for="edit-submitted-tribute-information-toggle-wrapper-paper-card-fields-shipping-address-line-2" class="replaced">Shipping Address Line 2 </label>
</div>
<div class="form-item webform-component webform-component-textfield control-group" id="webform-component-tribute-information--toggle-wrapper--paper-card-fields--shipping-city">
<input type="text" id="edit-submitted-tribute-information-toggle-wrapper-paper-card-fields-shipping-city" name="submitted[tribute_information][toggle_wrapper][paper_card_fields][shipping_city]" value="" size="60" maxlength="128"
class="form-text" placeholder="Shipping City "><label for="edit-submitted-tribute-information-toggle-wrapper-paper-card-fields-shipping-city" class="replaced">Shipping City </label>
</div>
<div class="form-item webform-component webform-component-select control-group" id="webform-component-tribute-information--toggle-wrapper--paper-card-fields--shipping-state-province">
<label for="edit-submitted-tribute-information-toggle-wrapper-paper-card-fields-shipping-state-province">Shipping State/Province </label>
<div class="select-wrapper"><select id="edit-submitted-tribute-information-toggle-wrapper-paper-card-fields-shipping-state-province" name="submitted[tribute_information][toggle_wrapper][paper_card_fields][shipping_state_province]"
class="form-select" placeholder="">
<option value="" selected="selected">- None -</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="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="MH">Marshall Islands</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 Marianas Islands</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PW">Palau</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="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VI">Virgin Islands</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select></div>
</div>
<div class="form-item webform-component webform-component-textfield control-group" id="webform-component-tribute-information--toggle-wrapper--paper-card-fields--shipping-zip-postal">
<input type="text" id="edit-submitted-tribute-information-toggle-wrapper-paper-card-fields-shipping-zip-postal" name="submitted[tribute_information][toggle_wrapper][paper_card_fields][shipping_zip_postal]" value="" size="60"
maxlength="128" class="form-text" placeholder="Shipping Zip/Postal "><label for="edit-submitted-tribute-information-toggle-wrapper-paper-card-fields-shipping-zip-postal" class="replaced">Shipping Zip/Postal </label>
</div>
<div class="form-item webform-component webform-component-select control-group" id="webform-component-tribute-information--toggle-wrapper--paper-card-fields--shipping-country">
<label for="edit-submitted-tribute-information-toggle-wrapper-paper-card-fields-shipping-country">Shipping Country </label>
<div class="select-wrapper"><select id="edit-submitted-tribute-information-toggle-wrapper-paper-card-fields-shipping-country" name="submitted[tribute_information][toggle_wrapper][paper_card_fields][shipping_country]"
class="form-select" placeholder="">
<option value="AF">Afghanistan</option>
<option value="AX">Aland Islands</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BW">Botswana</option>
<option value="BV">Bouvet Island</option>
<option value="BR">Brazil</option>
<option value="IO">British Indian Ocean Territory</option>
<option value="VG">British Virgin Islands</option>
<option value="BN">Brunei</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</option>
<option value="BQ">Caribbean Netherlands</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo (Brazzaville)</option>
<option value="CD">Congo (Kinshasa)</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CW">Curaçao</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="GG">Guernsey</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard Island and McDonald Islands</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong S.A.R., China</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IR">Iran</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IM">Isle of Man</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="CI">Ivory Coast</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JE">Jersey</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Laos</option>
<option value="LV">Latvia</option>
<option value="LB">Lebanon</option>
<option value="LS">Lesotho</option>
<option value="LR">Liberia</option>
<option value="LY">Libya</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macao S.A.R., China</option>
<option value="MK">Macedonia</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MH">Marshall Islands</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia</option>
<option value="MD">Moldova</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="ME">Montenegro</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="MM">Myanmar</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="AN">Netherlands Antilles</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="MP">Northern Mariana Islands</option>
<option value="KP">North Korea</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PS">Palestinian Territory</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="BL">Saint Barthélemy</option>
<option value="SH">Saint Helena</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="MF">Saint Martin (French part)</option>
<option value="PM">Saint Pierre and Miquelon</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">Sao Tome and Principe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="RS">Serbia</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SX">Sint Maarten</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="GS">South Georgia and the South Sandwich Islands</option>
<option value="KR">South Korea</option>
<option value="SS">South Sudan</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard and Jan Mayen</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syria</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="TL">Timor-Leste</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="VI">U.S. Virgin Islands</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US" selected="selected">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VA">Vatican</option>
<option value="VE">Venezuela</option>
<option value="VN">Vietnam</option>
<option value="WF">Wallis and Futuna</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select></div>
</div>
</div>
</fieldset>
</div>
</fieldset>
</div>
</fieldset>
<fieldset class="webform-component-fieldset form-wrapper" id="webform-component-payment-information">
<legend><span class="fieldset-legend">Payment Details</span></legend>
<div class="fieldset-wrapper">
<div class="form-item webform-component webform-component-radios control-group" id="webform-component-payment-information--payment-method">
<label for="edit-submitted-payment-information-payment-method">Payment Method <span class="form-required" title="This field is required.">*</span></label>
<div id="edit-submitted-payment-information-payment-method">
<div class="form-item form-type-radio form-item-submitted-payment-information-payment-method control-group">
<input class="fundraiser-payment-methods" type="radio" id="edit-submitted-payment-information-payment-method-1" name="submitted[payment_information][payment_method]" value="credit" placeholder=""> <label class="option"
for="edit-submitted-payment-information-payment-method-1">Credit Card </label>
</div>
<div class="form-item form-type-radio form-item-submitted-payment-information-payment-method control-group">
<input class="fundraiser-payment-methods" type="radio" id="edit-submitted-payment-information-payment-method-2" name="submitted[payment_information][payment_method]" value="paypal" checked="checked" placeholder=""> <label class="option"
for="edit-submitted-payment-information-payment-method-2">PayPal </label>
</div>
<div class="form-item form-type-radio form-item-submitted-payment-information-payment-method control-group">
<input class="fundraiser-payment-methods" type="radio" id="edit-submitted-payment-information-payment-method-3" name="submitted[payment_information][payment_method]" value="bank account" placeholder=""> <label class="option"
for="edit-submitted-payment-information-payment-method-3">Bank Account </label>
</div>
</div>
</div>
<div class="webform-component-fieldset form-wrapper" id="webform-component-payment-information--payment-fields">
<fieldset class="fundraiser-payment-fields form-wrapper" id="edit-submitted-payment-information-payment-fields-credit" style="display: none;">
<div class="fieldset-wrapper">
<div class="form-item form-type-textfield form-item-submitted-payment-information-payment-fields-credit-card-number control-group">
<input class="input-large form-text" autocomplete="off" type="text" id="edit-submitted-payment-information-payment-fields-credit-card-number" name="submitted[payment_information][payment_fields][credit][card_number]" value="" size="20"
maxlength="128" placeholder="Credit card number "><label for="edit-submitted-payment-information-payment-fields-credit-card-number" class="replaced">Credit card number </label>
</div>
<div class="expiration-date-wrapper clear-block">
<div class="form-item form-type-select form-item-submitted-payment-information-payment-fields-credit-expiration-date-card-expiration-month control-group">
<label for="edit-submitted-payment-information-payment-fields-credit-expiration-date-card-expiration-month">Expiration date </label>
<div class="select-wrapper"><select class="input-small form-select" id="edit-submitted-payment-information-payment-fields-credit-expiration-date-card-expiration-month"
name="submitted[payment_information][payment_fields][credit][expiration_date][card_expiration_month]" placeholder="">
<option value="1">January</option>
<option value="2">February</option>
<option value="3">March</option>
<option value="4">April</option>
<option value="5">May</option>
<option value="6">June</option>
<option value="7">July</option>
<option value="8">August</option>
<option value="9">September</option>
<option value="10">October</option>
<option value="11" selected="selected">November</option>
<option value="12">December</option>
</select></div>
<div class="select-wrapper"><select class="input-small form-select" id="edit-submitted-payment-information-payment-fields-credit-expiration-date-card-expiration-year"
name="submitted[payment_information][payment_fields][credit][expiration_date][card_expiration_year]" placeholder="">
<option value="2024" selected="selected">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>
<option value="2034">2034</option>
<option value="2035">2035</option>
<option value="2036">2036</option>
<option value="2037">2037</option>
<option value="2038">2038</option>
<option value="2039">2039</option>
</select></div>
</div>
</div>
<div class="form-item form-type-textfield form-item-submitted-payment-information-payment-fields-credit-card-cvv control-group">
<input class="input-small form-text" autocomplete="off" type="text" id="edit-submitted-payment-information-payment-fields-credit-card-cvv" name="submitted[payment_information][payment_fields][credit][card_cvv]" value="" size="6"
maxlength="128" placeholder="CVV "><label for="edit-submitted-payment-information-payment-fields-credit-card-cvv" class="replaced">CVV </label>
</div><input type="hidden" name="submitted[payment_information][payment_fields][credit][card_type]" value="" placeholder="">
</div>
</fieldset>
<fieldset class="fundraiser-payment-fields form-wrapper" id="edit-submitted-payment-information-payment-fields-paypal">
<div class="fieldset-wrapper">
<div id="payment-details" class="form-wrapper">
<div id="braintree-payment-form-outer">
<div class="braintree-payment-form form-wrapper" id="edit-submitted-payment-information-payment-fields-paypal-braintree-new">
<div id="paypal-container" class="form-wrapper">
<div id="braintree-paypal-loggedin" class="form-wrapper"><span id="bt-pp-name">PayPal</span><span id="bt-pp-email"></span><button id="bt-pp-cancel">Cancel</button></div>
</div>
</div>
</div>
</div><input type="hidden" name="braintree[errors]" value="" placeholder="">
<input type="hidden" name="payment_method_nonce" value="" placeholder="">
<input type="hidden" name="submitted[payment_information][payment_fields][paypal][braintree_card_type]" value="" placeholder="">
<input type="hidden" name="submitted[payment_information][payment_fields][paypal][braintree_last4]" value="" placeholder="">
</div>
</fieldset>
<fieldset class="fundraiser-payment-fields form-wrapper" id="edit-submitted-payment-information-payment-fields-bank-account" style="display: none;">
<div class="fieldset-wrapper">
<div class="form-item form-type-textfield form-item-submitted-payment-information-payment-fields-bank account-routing-number control-group">
<input autocomplete="off" type="text" id="edit-submitted-payment-information-payment-fields-bank-account-routing-number" name="submitted[payment_information][payment_fields][bank account][routing_number]" value="" size="10"
maxlength="9" class="form-text" placeholder="Routing Number "><label for="edit-submitted-payment-information-payment-fields-bank-account-routing-number" class="replaced">Routing Number </label>
</div>
<div class="form-item form-type-textfield form-item-submitted-payment-information-payment-fields-bank account-account-number control-group">
<input autocomplete="off" type="text" id="edit-submitted-payment-information-payment-fields-bank-account-account-number" name="submitted[payment_information][payment_fields][bank account][account_number]" value="" size="21"
maxlength="20" class="form-text" placeholder="Account Number "><label for="edit-submitted-payment-information-payment-fields-bank-account-account-number" class="replaced">Account Number </label>
</div>
<div class="form-item form-type-textfield form-item-submitted-payment-information-payment-fields-bank account-confirm-account-number control-group">
<input autocomplete="off" type="text" id="edit-submitted-payment-information-payment-fields-bank-account-confirm-account-number" name="submitted[payment_information][payment_fields][bank account][confirm_account_number]" value=""
size="21" maxlength="20" class="form-text" placeholder="Confirm Account Number "><label for="edit-submitted-payment-information-payment-fields-bank-account-confirm-account-number" class="replaced">Confirm Account Number </label>
</div>
<div class="form-item form-type-select form-item-submitted-payment-information-payment-fields-bank account-account-type control-group">
<label for="edit-submitted-payment-information-payment-fields-bank-account-account-type">Account Type </label>
<div class="select-wrapper"><select id="edit-submitted-payment-information-payment-fields-bank-account-account-type" name="submitted[payment_information][payment_fields][bank account][account_type]" class="form-select" placeholder="">
<option value="checking">Checking</option>
<option value="savings">Savings</option>
</select></div>
</div>
<div class="form-item form-type-textfield form-item-submitted-payment-information-payment-fields-bank account-bank-name control-group">
<input autocomplete="off" type="text" id="edit-submitted-payment-information-payment-fields-bank-account-bank-name" name="submitted[payment_information][payment_fields][bank account][bank_name]" value="" size="32" maxlength="50"
class="form-text" placeholder="Bank Name "><label for="edit-submitted-payment-information-payment-fields-bank-account-bank-name" class="replaced">Bank Name </label>
</div>
<div class="form-item form-type-textfield form-item-submitted-payment-information-payment-fields-bank account-acct-name control-group">
<input autocomlete="off" type="text" id="edit-submitted-payment-information-payment-fields-bank-account-acct-name" name="submitted[payment_information][payment_fields][bank account][acct_name]" value="" size="32" maxlength="22"
class="form-text" placeholder="Account Owner "><label for="edit-submitted-payment-information-payment-fields-bank-account-acct-name" class="replaced">Account Owner </label>
</div>
</div>
</fieldset>
<fieldset class="fundraiser-payment-fields form-wrapper" id="edit-submitted-payment-information-payment-fields-applepay" style="display: none;">
<div class="fieldset-wrapper"><input type="hidden" name="payment_method_nonce" value="" placeholder="">
<input type="hidden" name="payment_method_nonce" value="" placeholder="">
<input type="hidden" name="submitted[payment_information][payment_fields][applepay][braintree_card_type]" value="" placeholder="">
<input type="hidden" name="submitted[payment_information][payment_fields][applepay][braintree_last4]" value="" placeholder="">
</div>
</fieldset>
</div><input type="hidden" name="submitted[payment_information][processing_fee_amount]" value="" placeholder="">
</div>
</fieldset>
<fieldset class="webform-component-fieldset form-wrapper" id="webform-component-donor-information" style="display: none;">
<legend><span class="fieldset-legend">My Information</span></legend>
<div class="fieldset-wrapper">
<div class="form-item webform-component webform-component-textfield control-group" id="webform-component-donor-information--first-name">
<input type="text" id="edit-submitted-donor-information-first-name" name="submitted[donor_information][first_name]" value="" size="60" maxlength="128" class="form-text required" placeholder="First Name *"><label
for="edit-submitted-donor-information-first-name" class="replaced">First Name <span class="form-required" title="This field is required.">*</span></label>
</div>
<div class="form-item webform-component webform-component-textfield control-group" id="webform-component-donor-information--last-name">
<input type="text" id="edit-submitted-donor-information-last-name" name="submitted[donor_information][last_name]" value="" size="60" maxlength="128" class="form-text required" placeholder="Last Name *"><label
for="edit-submitted-donor-information-last-name" class="replaced">Last Name <span class="form-required" title="This field is required.">*</span></label>
</div>
<div class="form-item webform-component webform-component-email control-group" id="webform-component-donor-information--mail">
<input class="email form-text form-email required" type="email" id="edit-submitted-donor-information-mail" name="submitted[donor_information][mail]" size="60" placeholder="E-mail address *"><label for="edit-submitted-donor-information-mail"
class="replaced">E-mail address <span class="form-required" title="This field is required.">*</span></label>
</div>
</div>
</fieldset>
<fieldset class="webform-component-fieldset form-wrapper" id="webform-component-billing-information" style="display: none;">
<legend><span class="fieldset-legend">Billing Information</span></legend>
<div class="fieldset-wrapper">
<div class="form-item webform-component webform-component-textfield control-group" id="webform-component-billing-information--address">
<input type="text" id="edit-submitted-billing-information-address" name="submitted[billing_information][address]" value="" size="60" maxlength="100" class="form-text required" placeholder="Address *"><label
for="edit-submitted-billing-information-address" class="replaced">Address <span class="form-required" title="This field is required.">*</span></label>
</div>
<div class="form-item webform-component webform-component-textfield control-group" id="webform-component-billing-information--address-line-2">
<input type="text" id="edit-submitted-billing-information-address-line-2" name="submitted[billing_information][address_line_2]" value="" size="60" maxlength="128" class="form-text" placeholder="Address Line 2 "><label
for="edit-submitted-billing-information-address-line-2" class="replaced">Address Line 2 </label>
</div>
<div class="form-item webform-component webform-component-textfield control-group" id="webform-component-billing-information--zip">
<input class="input-medium form-text required springboard-ztc-processed" type="text" id="edit-submitted-billing-information-zip" name="submitted[billing_information][zip]" value="" size="10" maxlength="10"
placeholder="ZIP/Postal Code *"><label for="edit-submitted-billing-information-zip" class="replaced">ZIP/Postal Code <span class="form-required" title="This field is required.">*</span></label>
</div>
<div class="form-item webform-component webform-component-select control-group" id="webform-component-billing-information--country">
<label for="edit-submitted-billing-information-country">Country <span class="form-required" title="This field is required.">*</span></label>
<div class="select-wrapper"><select id="edit-submitted-billing-information-country" name="submitted[billing_information][country]" class="form-select required ajax-processed" placeholder="">
<option value="CA">Canada</option>
<option value="US" selected="selected">United States</option>
</select></div>
</div>
<div class="form-item webform-component webform-component-textfield control-group" id="webform-component-billing-information--city">
<input type="text" id="edit-submitted-billing-information-city" name="submitted[billing_information][city]" value="" size="60" maxlength="128" class="form-text required" placeholder="City *"><label
for="edit-submitted-billing-information-city" class="replaced">City <span class="form-required" title="This field is required.">*</span></label>
</div>
<div id="zone-select-wrapper">
<div class="form-item webform-component webform-component-select control-group" id="webform-component-billing-information--state">
<label for="edit-submitted-billing-information-state">State/Province <span class="form-required" title="This field is required.">*</span></label>
<div class="select-wrapper"><select id="edit-submitted-billing-information-state" name="submitted[billing_information][state]" class="form-select required" placeholder="">
<option value="" selected="selected">- Select -</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</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="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="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</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="UT">Utah</option>
<option value="VT">Vermont</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>
<option value=" ">--</option>
<option value="AA">Armed Forces (Americas)</option>
<option value="AE">Armed Forces (Europe, Canada, Middle East, Africa)</option>
<option value="AP">Armed Forces (Pacific)</option>
<option value="AS">American Samoa</option>
<option value="FM">Federated States of Micronesia</option>
<option value="GU">Guam</option>
<option value="MH">Marshall Islands</option>
<option value="MP">Northern Mariana Islands</option>
<option value="PW">Palau</option>
<option value="PR">Puerto Rico</option>
<option value="VI">Virgin Islands</option>
</select></div>
</div>
</div>
</div>
</fieldset>
<input type="hidden" name="submitted[ms]" value="WEZ25EG" placeholder="">
<input type="hidden" name="submitted[cid]" value="7015G0000003jWfQAI" placeholder="">
<input type="hidden" name="submitted[referrer]" value="" placeholder="">
<input type="hidden" name="submitted[initial_referrer]" value="" placeholder="">
<input type="hidden" name="submitted[search_engine]" value="" placeholder="">
<input type="hidden" name="submitted[secure_prepop_autofilled]" value="0" placeholder="">
<input type="hidden" name="submitted[springboard_cookie_autofilled]" value="disabled" placeholder="">
<input type="hidden" name="submitted[content_override_id]" value="" placeholder="">
<input type="hidden" name="submitted[search_string]" value="" placeholder="">
<input type="hidden" name="submitted[user_agent]" value="Mozilla/5.0 (X11; Linux x86_64) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/131.0.0.0 Safari/537.36" class="marketsource-processed" placeholder="">
<input type="hidden" name="submitted[utm_source]" value="WEZ25EG" placeholder="">
<input type="hidden" name="submitted[utm_medium]" value="" placeholder="">
<input type="hidden" name="submitted[utm_term]" value="" placeholder="">
<input type="hidden" name="submitted[utm_content]" value="" placeholder="">
<input type="hidden" name="submitted[utm_campaign]" value="" placeholder="">
<input type="hidden" name="submitted[eml_name]" value="" placeholder="">
<input type="hidden" name="submitted[eml_id]" value="" placeholder="">
<input type="hidden" name="submitted[device_browser]" value="" placeholder="">
<input type="hidden" name="submitted[device_name]" value="" placeholder="">
<input type="hidden" name="submitted[device_os]" value="" placeholder="">
<input type="hidden" name="submitted[device_type]" value="" placeholder="">
<input type="hidden" name="submitted[social_referer_transaction]" value="" placeholder="">
<input type="hidden" name="submitted[gs_flag]" value="None" placeholder="">
<input type="hidden" name="submitted[full_address]" value=" " placeholder="">
<input type="hidden" name="submitted[premium_to_send]" value="" placeholder="">
<input type="hidden" name="details[sid]" placeholder="">
<input type="hidden" name="details[page_num]" value="1" placeholder="">
<input type="hidden" name="details[page_count]" value="1" placeholder="">
<input type="hidden" name="details[finished]" value="0" placeholder="">
<input type="hidden" name="form_build_id" value="form-2dLky4xgBNiapdIaEKwFa51OOyDjRmdvrMQT3JtCf3c" placeholder="">
<input type="hidden" name="form_id" value="webform_client_form_61" placeholder="">
<a name="payment-section"></a><input type="hidden" name="springboard_fraud_token" value="" class="springboardFraudToken-processed" placeholder="">
<input type="hidden" name="springboard_fraud_js_detect" value="1" placeholder="">
<div class="fundraiser_submit_message"><img typeof="foaf:Image" src="https://secure.pva.org/sites/all/modules/springboard/fundraiser/modules/fundraiser_webform/images/padlock.png" alt="">By clicking SUBMIT your credit card will be securely
processed.</div>
<div class="form-actions form-wrapper" id="edit-actions">
<div class="btn submit">Donate Monthly now <span>Amount: $24.00</span></div><input class="btn jquery-once-6-processed" type="submit" id="edit-submit" name="op" value="Submit" placeholder="" style="display: none;">
<div class="donation-processing-wrapper" style="display: none;">
<p class="donation-processing">Processing <span class="donation-processing-spinner"></span></p>
</div>
</div>
<fieldset class="form-wrapper" id="edit-recent-donations-block">
<div class="fieldset-wrapper"></div>
</fieldset>
</form>Text Content
Skip to main content * Donor Login * Help and Information DONATION FORM - WITH TRIBUTE/HONOR FIELDS Many of our nation’s paralyzed and disabled heroes need help accessing their much-needed benefits, medical care, and support services. With your monthly support, we will always be there to connect them to those life-changing resources. My Donation One-time Monthly $19 * $24 * $30 * $35 * Other * Other $ Minimum payment $5.00. $25 $50 $100 $250 Other Other $ Minimum payment $5.00. Add 3% to my donation to cover credit card fees. Dedicate my donation in honor of or in memorial of someone. Honoree Name Occasion - None -In honor ofIn memory of Would you like to send an eCard? No Yes Recipient First Name Recipient Last Name Recipient e-mail address eCard subject eCard message Would you like to send a paper card? No Yes Shipping First Name Shipping Last Name Shipping Address Shipping Address Line 2 Shipping City Shipping State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Shipping Zip/Postal Shipping Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong S.A.R., ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe Payment Details Payment Method * Credit Card PayPal Bank Account Credit card number Expiration date JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 2024202520262027202820292030203120322033203420352036203720382039 CVV PayPalCancel Routing Number Account Number Confirm Account Number Account Type CheckingSavings Bank Name Account Owner My Information First Name * Last Name * E-mail address * Billing Information Address * Address Line 2 ZIP/Postal Code * Country * CanadaUnited States City * State/Province * - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--Armed Forces (Americas)Armed Forces (Europe, Canada, Middle East, Africa)Armed Forces (Pacific)American SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin Islands By clicking SUBMIT your credit card will be securely processed. Donate Monthly now Amount: $24.00 Processing 0 © 2024 Paralyzed Veterans of America. All Rights Reserved. Paralyzed Veterans of America is a 501(c)(3) tax-exempt, non-profit organization. * Sitemap * Privacy Policy * Terms of Use * Financial Information Close HELP & INFORMATION Is my donation secure? The security and confidentiality of your information is our highest priority. We use industry-standard SSL (secure socket layer) technology to protect your information and provide a safe and secure environment for online donations. We will not sell, trade or share your personal information with anyone else, nor send donor mailings on behalf of other organizations. Do I get a receipt? A donation receipt will be sent to you at the email address you provide on this form. Please be sure to keep a copy of your receipt for tax purposes. If you select a recurring donation, you will be sent an individual receipt each month when your donation is processed. Can I select my t-shirt size? All t-shirts are size XL. When you receive yours, we'd love to see you wearing it! Tag your social media photos with #PVAHero. To give by phone: Please call us at 1-800-555-9140 To send in a check: PVA National Processing Center P.O. Box 758589 Topeka, KS 66675-8542