www.apdaparkinson.org
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Submitted URL: https://default.salsalabs.org/T6ba01ab3-606e-4a41-9e67-343ad0f62d43/7b245d9c-9038-45c9-85d1-e18b88ff0605
Effective URL: https://www.apdaparkinson.org/0000d6l/?utm_medium=email&utm_source=salsa&utm_campaign=thd-apda-23-04-em-aprilmatch-conv&utm_co...
Submission: On April 04 via manual from US — Scanned from DE
Effective URL: https://www.apdaparkinson.org/0000d6l/?utm_medium=email&utm_source=salsa&utm_campaign=thd-apda-23-04-em-aprilmatch-conv&utm_co...
Submission: On April 04 via manual from US — Scanned from DE
Form analysis 2 forms found in the DOM
GET https://www.apdaparkinson.org/
<form role="search" method="get" class="search-form" action="https://www.apdaparkinson.org/">
<label>
<span class="screen-reader-text">Search for:</span>
<input type="search" class="search-field" placeholder="Search …" value="" name="s">
</label>
<input type="submit" class="search-submit" value="Search">
</form><form class="sli-form fv-form fv-form-salsa" data-fv-framework="salsa" novalidate="novalidate" data-ignite-form-id="30c265bb-774d-4f10-aa6e-6e0876a69a2e" id="form_igWSTtTjGyPz">
<div class="sli-row" id="id_fcf72dbb-f053-4b2b-864b-642b84b098a0">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="elementStep" id="id_00441fcd-fcbe-4be3-a560-0176dc8a393a" data-ignite-step-id="1">
<div class="sli-row" id="id_589510f4-64fc-4862-ac8c-1a782370ae93">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_afa4c192-4f2d-4b11-93d2-db03d2eec764"></div>
</div>
<div class="sli-element sli-text" id="id_118224ff-8d15-4ac2-97d6-108b5209c062">
<div id="id_118224ff-8d15-4ac2-97d6-108b5209c062_inner">
<h3> Donation Amount </h3>
</div>
</div>
<div class="sli-row" id="id_4b0f94bd-90e3-46c2-8e95-d39fdb543144">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_d716661c-1505-4b7a-921b-7c1032b14ed0">
<div class="sli-donation-amountblock sli-element" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311" 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_f0127c5d-4f41-4afe-8ee7-75202674f311_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_f0127c5d-4f41-4afe-8ee7-75202674f311_onetime_amt_25" type="radio" data-ignite-amount="25.00" data-fv-onetimeamount="true" data-sli-widget="_igWSTtTjGyPz"
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-flat" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_onetime_amt_25_label" for="id_f0127c5d-4f41-4afe-8ee7-75202674f311_onetime_amt_25">$25</label></li>
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_onetime_amt_35" type="radio" data-ignite-amount="35.00" data-fv-field="donationAmtToggle"
data-sli-widget="_igWSTtTjGyPz"><label class="sli-oneTimeAmountLabel sli-amount-label sli-small sli-flat" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_onetime_amt_35_label"
for="id_f0127c5d-4f41-4afe-8ee7-75202674f311_onetime_amt_35">$35</label></li>
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_onetime_amt_50" type="radio" data-ignite-amount="50.00" data-fv-field="donationAmtToggle"
data-sli-widget="_igWSTtTjGyPz"><label class="sli-oneTimeAmountLabel sli-amount-label sli-small sli-flat" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_onetime_amt_50_label"
for="id_f0127c5d-4f41-4afe-8ee7-75202674f311_onetime_amt_50">$50</label></li>
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_onetime_amt_75" type="radio" data-ignite-amount="75.00" data-fv-field="donationAmtToggle"
data-sli-widget="_igWSTtTjGyPz"><label class="sli-oneTimeAmountLabel sli-amount-label sli-small sli-flat" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_onetime_amt_75_label"
for="id_f0127c5d-4f41-4afe-8ee7-75202674f311_onetime_amt_75">$75</label></li>
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_onetime_amt_100" type="radio" data-ignite-amount="100.00" data-fv-field="donationAmtToggle"
data-sli-widget="_igWSTtTjGyPz"><label class="sli-oneTimeAmountLabel sli-amount-label sli-small sli-flat" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_onetime_amt_100_label"
for="id_f0127c5d-4f41-4afe-8ee7-75202674f311_onetime_amt_100">$100</label></li>
<li><input class="sli-oneTimeAmountRadio sli-oneTimeCustomAmount" name="donationAmtToggleOther" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_onetime_custom_radio" type="radio" data-ignite-custom-onetime="data-ignite-custom-onetime"
data-sli-widget="_igWSTtTjGyPz">
<div class="sli-input-group"> <span class="sli-oneTimeAmountLabel sli-amount-label sli-customAmount sli-input-group-label sli-small sli-flat" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_onetime_custom_label"
for="id_f0127c5d-4f41-4afe-8ee7-75202674f311_onetime_custom" autocomplete="off">$</span> <input class="sli-oneTimeAmountInput sli-customAmount sli-input sli-input-group-field" size="5"
id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_onetime_custom" type="text" placeholder="Other" name="customOneTime" data-ignite-custom-onetime-input="data-ignite-custom-onetime-input" 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" autocomplete="off" 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_f0127c5d-4f41-4afe-8ee7-75202674f311_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_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_5" type="radio" data-ignite-amount="5.00" data-fv-recurringamount="true" data-sli-widget="_igWSTtTjGyPz"
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-flat" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_5_label" for="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_5">$5</label></li>
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_10" type="radio" data-ignite-amount="10.00" data-fv-field="donationAmtToggle2"
data-sli-widget="_igWSTtTjGyPz"><label class="sli-recurringAmountLabel sli-amount-label sli-small sli-flat" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_10_label"
for="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_10">$10</label></li>
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_15" type="radio" data-ignite-amount="15.00" data-fv-field="donationAmtToggle2"
data-sli-widget="_igWSTtTjGyPz"><label class="sli-recurringAmountLabel sli-amount-label sli-small sli-flat" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_15_label"
for="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_15">$15</label></li>
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_20" type="radio" data-ignite-amount="20.00" data-fv-field="donationAmtToggle2"
data-sli-widget="_igWSTtTjGyPz"><label class="sli-recurringAmountLabel sli-amount-label sli-small sli-flat" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_20_label"
for="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_20">$20</label></li>
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_25" type="radio" data-ignite-amount="25.00" data-fv-field="donationAmtToggle2"
data-sli-widget="_igWSTtTjGyPz"><label class="sli-recurringAmountLabel sli-amount-label sli-small sli-flat" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_25_label"
for="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_25">$25</label></li>
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_50" type="radio" data-ignite-amount="50.00" data-fv-field="donationAmtToggle2"
data-sli-widget="_igWSTtTjGyPz"><label class="sli-recurringAmountLabel sli-amount-label sli-small sli-flat" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_50_label"
for="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_50">$50</label></li>
<li><input class="sli-recurringAmountRadio sli-recurringCustomAmount" name="donationAmtToggle2Other" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_custom_radio" type="radio"
data-ignite-custom-recurring="data-ignite-custom-recurring" data-sli-widget="_igWSTtTjGyPz">
<div class="sli-input-group"> <span class="sli-recurringAmountLabel sli-amount-label sli-customAmount sli-input-group-label sli-small sli-flat" id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_custom_label"
for="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_custom_radio" autocomplete="off">$</span> <input class="sli-recurringAmountInput sli-customAmount sli-input sli-input-group-field" size="5"
id="id_f0127c5d-4f41-4afe-8ee7-75202674f311_recurringAmt_custom" type="text" placeholder="Other" name="customRecurringAmount" data-ignite-custom-recurring-input="data-ignite-custom-recurring-input"
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_b1f31cca-9ba7-4d2f-a5af-9f245ea0752f">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_fb9eb0e4-634b-4522-898e-c5c6e56ee4df">
<div class="sli-selectRecurring sli-element" id="id_c6f27cbe-04d1-4c17-aa32-c9a0bfd35098" data-ignite-field-id="MakeRecurring"> <input class="sli-input" id="id_c6f27cbe-04d1-4c17-aa32-c9a0bfd35098_makeRecurring_input" type="checkbox"
name="makeRecurring" value="true" style="margin-right: 5px;" salsa-reference-name="makerecurringcb">Make this donation recurring </div>
</div>
</div>
<div class="sli-row" id="id_3c900e59-8428-4da3-ae57-8b4dc384f6d0">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_1aea8cb0-32ac-4038-83a6-22feead1ec97">
<div class="sli-element sli-text" id="id_01c31845-7bce-45eb-8337-024cc5cd1a58">
<div id="id_01c31845-7bce-45eb-8337-024cc5cd1a58_inner">
<h3> Payment Details </h3>
</div>
</div>
<div class="sli-donation-paymentblock sli-element" id="id_ad57f6e7-0382-4968-9ddc-8070857d9116">
<div class="sli-paymentType" id="id_ad57f6e7-0382-4968-9ddc-8070857d9116_paymentType">
<div class="sli-ccType sli-label" for="payment_type"> Payment Type: </div> <input name="payment_type" type="radio" value="CREDIT_CARD" checked="checked" id="BTktUDjwZX"> <label class="sli-label" for="BTktUDjwZX">Credit Card</label>
<input name="payment_type" sli-payment-type="ACH" style="display:none;" type="radio" value="ACH" id="GsMTYGEiVg"> <label class="sli-label" style="display:none;" sli-payment-type="ACH" for="GsMTYGEiVg">eCheck</label> <input
name="payment_type" sli-payment-type="PAYPAL" style="display:none;" type="radio" value="PAYPAL" id="rjWTxTSenN"> <label class="sli-label" style="display:none;" sli-payment-type="PAYPAL" for="rjWTxTSenN">PayPal</label>
</div>
<div id="id_ad57f6e7-0382-4968-9ddc-8070857d9116_echeck_wepay" data-ignite-echeck-wepay="ignite-echeck-wepay"> <label class="sli-ccLabel sli-label" for="QLOWQTptXz">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="QLOWQTptXz" 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_ad57f6e7-0382-4968-9ddc-8070857d9116_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_ad57f6e7-0382-4968-9ddc-8070857d9116_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="kRJATmtTOB">Name on Account*</label> <input class="sli-ccInput sli-input" type="text" name="holder_name"
id="kRJATmtTOB" 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="NEMQJOAGxb">Bank Routing Number*</label> <input class="sli-ccInput sli-input" type="text" name="bank_routing" id="NEMQJOAGxb"
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="MjqklMpekc">Bank Account Number*</label> <input class="sli-bankAccount sli-ccInput sli-input" type="text" name="bank_account"
id="MjqklMpekc" 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_ad57f6e7-0382-4968-9ddc-8070857d9116_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="wdZSvHxIPr">Card Number*</label> <input class="sli-ccInput sli-input" name="card_number" id="wdZSvHxIPr" 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="GKADLzvWUO">Security Code*</label> <input class="sli-ccExpCcvInput sli-input" name="cvv" id="GKADLzvWUO"
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="JHyGAElbCB">Expiration Month*</label> <select class="sli-ccInput sli-input" name="expiry_month" id="JHyGAElbCB"
required="required" data-fv-notempty-message="Month is required" style="display: block;" data-fv-field="expiry_month">
<option value="">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="mBlgfreGzJ">Expiration Year*</label> <select class="sli-ccInput sli-input" name="expiry_year" id="mBlgfreGzJ"
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="duOzmRWzRj">Name on Card*</label> <input class="sli-ccNameInput sli-input" name="name_on_card" id="duOzmRWzRj"
type="text" 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_2ca3e66d-1d0f-4a7f-9c99-da46b58dd438">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_c81dc22c-5c01-4b7e-9127-9cfa34769ec7">
<div class="sli-element sli-text" id="id_a02d0b1c-2820-4266-9138-db0a8c9805c4">
<div id="id_a02d0b1c-2820-4266-9138-db0a8c9805c4_inner">
<h3> Your Info </h3>
</div>
</div>
</div>
</div>
<div class="sli-row" id="id_ccac321c-a9da-4e0e-951d-5628ed21232f">
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_a944b693-7612-4138-bdb2-3768ec154cd2">
<div class="sli-field-contact-email sli-form-field sli-element" data-ignite-field-id="2851b463-606f-40c8-bb3d-d31f399e6896" id="id_dd7546a0-92f0-4c93-b592-cee64e906907"> <label class="sli-required-true sli-label"
for="id_dd7546a0-92f0-4c93-b592-cee64e906907_input" id="id_dd7546a0-92f0-4c93-b592-cee64e906907_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_dd7546a0-92f0-4c93-b592-cee64e906907_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>
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_3c77fb45-20bc-4591-9238-abbc4d6b4dd8">
<div class="sli-field-person-home_phone sli-form-field sli-element" data-ignite-field-id="6e201e0b-8208-453f-b393-a5f0d9059726" id="id_3007c48f-ddae-4782-9e39-0a474865537f"> <label class="sli-required-false sli-label"
for="id_3007c48f-ddae-4782-9e39-0a474865537f_input" id="id_3007c48f-ddae-4782-9e39-0a474865537f_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_3007c48f-ddae-4782-9e39-0a474865537f_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>
</div>
</div>
<div class="sli-row" id="id_5a0bc366-5870-4cb7-a075-0b16855ba9f3">
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_df58d833-a821-4689-8354-0c5e6e41d4ca">
<div class="sli-field-person-firstname sli-form-field sli-element" data-ignite-field-id="5d5a2165-f19e-4371-851b-183a6b92402b" id="id_975c4541-79f0-4720-acfb-5065e800bf30"> <label class="sli-required-true sli-label"
for="id_975c4541-79f0-4720-acfb-5065e800bf30_input" id="id_975c4541-79f0-4720-acfb-5065e800bf30_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_975c4541-79f0-4720-acfb-5065e800bf30_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 " data-ignite-container-type="DEFAULT" id="id_fce78db6-db4a-4a72-91ab-206014c9313c">
<div class="sli-field-person-lastname sli-form-field sli-element" data-ignite-field-id="8d21a878-287a-491f-a362-b8ee2aa71819" id="id_b8b14ab6-a548-4ec8-890f-7736d8a50d5e"> <label class="sli-required-true sli-label"
for="id_b8b14ab6-a548-4ec8-890f-7736d8a50d5e_input" id="id_b8b14ab6-a548-4ec8-890f-7736d8a50d5e_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_b8b14ab6-a548-4ec8-890f-7736d8a50d5e_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_8ee8cfce-85f6-4b44-bdbe-1d588504ae1e">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_c8fcd4a5-5c86-4d3c-b4c0-fd6e3db890f5">
<div class="sli-field-address-line1 sli-form-field sli-element" data-ignite-field-id="f775c79a-df41-43fb-96de-ee2360254689" id="id_41dd48de-9871-45dc-a4cf-165cce6946e8"> <label class="sli-required-true sli-label"
for="id_41dd48de-9871-45dc-a4cf-165cce6946e8_input" id="id_41dd48de-9871-45dc-a4cf-165cce6946e8_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_41dd48de-9871-45dc-a4cf-165cce6946e8_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_9caa5b60-fed5-41b1-a8d6-c6078d74148d"> <label class="sli-required-false sli-label"
for="id_9caa5b60-fed5-41b1-a8d6-c6078d74148d_input" id="id_9caa5b60-fed5-41b1-a8d6-c6078d74148d_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_9caa5b60-fed5-41b1-a8d6-c6078d74148d_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_4cd9cc4d-1fb9-4dbd-a68f-831972a47e92">
<div class="sli-large-4 sli-medium-4 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_c8760540-6d1b-4537-aff3-7fab0ac0475f">
<div class="sli-field-address-city sli-form-field sli-element" data-ignite-field-id="a102d60f-f8ab-47eb-8ee0-864cfa1fc5b2" id="id_452d0f00-4e06-4582-82f3-3270276a38f9"> <label class="sli-required-true sli-label"
for="id_452d0f00-4e06-4582-82f3-3270276a38f9_input" id="id_452d0f00-4e06-4582-82f3-3270276a38f9_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_452d0f00-4e06-4582-82f3-3270276a38f9_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_3182f739-634e-49f7-9a26-2c42906afb80">
<div class="sli-field-address-state sli-form-field sli-element" data-ignite-field-id="3f8b9098-ff2d-4384-bb95-425f113028c0" id="id_8adffc40-5237-4e3a-9f89-6eee9578c93a"> <label class="sli-required-true sli-label"
for="id_8adffc40-5237-4e3a-9f89-6eee9578c93a_input" id="id_8adffc40-5237-4e3a-9f89-6eee9578c93a_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_8adffc40-5237-4e3a-9f89-6eee9578c93a_input"
salsa-reference-name="address-state" data-fv-field="field-address-state">
<option value="">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 " data-ignite-container-type="DEFAULT" id="id_33da434a-bc90-436b-bee6-6a219452ecb9">
<div class="sli-field-address-zip sli-form-field sli-element" data-ignite-field-id="44e5ad15-1fdd-4ba8-bf38-f5cbaad023c2" id="id_94105615-d06b-48a7-bfb2-8d5e1471c6be"> <label class="sli-required-true sli-label"
for="id_94105615-d06b-48a7-bfb2-8d5e1471c6be_input" id="id_94105615-d06b-48a7-bfb2-8d5e1471c6be_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-country="US" data-fv-zipcode-message="This value is not valid as a %s postal code"
id="id_94105615-d06b-48a7-bfb2-8d5e1471c6be_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="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-field-address-country sli-form-field sli-element" data-ignite-field-id="f71a3605-b3a8-4650-af21-47387674a8eb" id="id_b98c9c6d-1f42-4128-8498-6be103b12dfb"> <label class="sli-required-true sli-label"
for="id_b98c9c6d-1f42-4128-8498-6be103b12dfb_input" id="id_b98c9c6d-1f42-4128-8498-6be103b12dfb_label">Country*</label> <select class="sli-select-address-country sli-input" name="field-address-country"
data-ignite-field-id="f71a3605-b3a8-4650-af21-47387674a8eb" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" id="id_b98c9c6d-1f42-4128-8498-6be103b12dfb_input"
salsa-reference-name="address-country" data-fv-field="field-address-country">
<option value="AF">Afghanistan</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia, Plurinational State of</option>
<option value="BQ">Bonaire, Sint Eustatius and Saba</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BW">Botswana</option>
<option value="BV">Bouvet Island</option>
<option value="BR">Brazil</option>
<option value="IO">British Indian Ocean Territory</option>
<option value="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="CV">Cabo Verde</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo</option>
<option value="CD">Congo, The Democratic Republic of the</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CW">Curaçao</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czechia</option>
<option value="CI">Côte d'Ivoire</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (Malvinas)</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="GG">Guernsey</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard Island and McDonald Islands</option>
<option value="VA">Holy See (Vatican City State)</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IR">Iran, Islamic Republic of</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IM">Isle of Man</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JE">Jersey</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KP">Korea, Democratic People's Republic of</option>
<option value="KR">Korea, Republic of</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Lao People's Democratic Republic</option>
<option value="LV">Latvia</option>
<option value="LB">Lebanon</option>
<option value="LS">Lesotho</option>
<option value="LR">Liberia</option>
<option value="LY">Libya</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macao</option>
<option value="MK">Macedonia, Republic of</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MH">Marshall Islands</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia, Federated States of</option>
<option value="MD">Moldova, Republic of</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="ME">Montenegro</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="MM">Myanmar</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="MP">Northern Mariana Islands</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PS">Palestine, State of</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RO">Romania</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="RE">Réunion</option>
<option value="BL">Saint Barthélemy</option>
<option value="SH">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="MF">Saint Martin (French part)</option>
<option value="PM">Saint Pierre and Miquelon</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">Sao Tome and Principe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="RS">Serbia</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SX">Sint Maarten (Dutch part)</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="GS">South Georgia and the South Sandwich Islands</option>
<option value="SS">South Sudan</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard and Jan Mayen</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syrian Arab Republic</option>
<option value="TW">Taiwan, Province of China</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania, United Republic of</option>
<option value="TH">Thailand</option>
<option value="TL">Timor-Leste</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US" selected="selected">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VE">Venezuela, Bolivarian Republic of</option>
<option value="VN">Viet Nam</option>
<option value="VG">Virgin Islands, British</option>
<option value="VI">Virgin Islands, U.S.</option>
<option value="WF">Wallis and Futuna</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
<option value="AX">Åland Islands</option>
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DIGITAL ACQUISITION – 0000D6L
APDA Donate to APDA
YES! $150,000 PARKINSON’S DISEASE AWARENESS MONTH GIFT CHALLENGE: MAKE YOUR
IMPACT TODAY!
WE NEED YOUR HELP TODAY TO REACH OUR $150,000 GIFT CHALLENGE GOAL. PLEASE JOIN
US BY MAKING A DONATION TODAY, OUR SUPPORT CAN GO THREE TIMES AS FAR TO HELP
PEOPLE WITH PARKINSON’S DISEASE (PD) LIVE LIFE TO THE FULLEST! THANK YOU FOR
INSPIRING STRENGTH AND OPTIMISM IN THE PD COMMUNITY.
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Your gift to the American Parkinson Disease Association truly makes a difference
in our efforts to provide the support, education and research that will help
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NEWSROOM
APDA IN THE NEWS
* ANTIEPILEPTIC MEDS TIED TO INCREASED PARKINSON RISK
* SPORT CLIMBING TIED TO IMPROVED POSTURE IN PARKINSON'S DISEASE
* APDA FUNDS $2.35M IN NEW ‘CUTTING-EDGE’ PARKINSON’S RESEARCH
* INCLUSION OF NON–ENGLISH-SPEAKING PARTICIPANTS IN STUDIES OF PARKINSON’S
DISEASE: A CALL TO ACTION
PRESS AND MEDIA
* AMERICAN PARKINSON DISEASE ASSOCIATION (APDA) KICKS-OFF 2023 NATIONAL
OPTIMISM WALK SERIES
* AMERICAN PARKINSON DISEASE ASSOCIATION TO CELEBRATE THE IMPORTANCE OF
COMMUNITY & CONNECTION DURING PARKINSON’S DISEASE AWARENESS MONTH
* AMERICAN PARKINSON DISEASE ASSOCIATION BRINGS TOP EXPERTS & PD COMMUNITY
TOGETHER FOR FREE TWO-DAY VIRTUAL EVENTDESIGNED TO EDUCATE, EMPOWER & ENGAGE
* HOPE IN PROGRESS: AMERICAN PARKINSON DISEASE ASSOCIATION SUPPORTS RESEARCHERS
WITH $2.35 MILLION IN NEW FUNDING
RECENT NEWS
* TWO DAYS OF EDUCATION & INSPIRATION
* LEARNING MORE ABOUT HOW LIFSTYLE AFFECTS PD
* APRIL IS PARKINSON’S DISEASE AWARENESS MONTH
* TIPS FROM A SOCIAL WORKER:
QUICK LINKS
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ABOUT APDA
The American Parkinson Disease Association (APDA) is the largest grassroots
network dedicated to fighting Parkinson’s disease (PD) and works tirelessly to
help the approximately one million with PD in the United States live life to the
fullest in the face of this chronic, neurological disorder. Founded in 1961,
APDA has raised and invested more than $226 million to provide outstanding
patient services and educational programs, elevate public awareness about the
disease, and support research designed to unlock the mysteries of PD and
ultimately put an end to this disease.
NATIONAL HEADQUARTERS
PO Box 61420
Staten Island, NY 10306
TEL: 800-223-2732
FAX: 718-981-4399
apda@apdaparkinson.org
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