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1 forms found in the DOM

Name: pb_EMF0424MatchingGiftAPR24 — POST /page/65175/donate/2

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        <div class="subtxt-" style="text-align: center; width: 100%; display: block; margin:auto;" width="70%"><span color="#000000" style="font-size:26px; line-height:31px; color:#000000;"><span style="color:#000000; font-weight: bold;">DOUBLE YOUR
              DONATION FOR EPILEPSY CARE, ADVOCACY, RESEARCH AND EDUCATION.</span></span></div>
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        <div class="en__component en__component--dd360search">
          <p>Many companies sponsor matching gift programs that increase the impact of your gift. See if your company will match your donation! (Optional)</p>
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              <label for="en__field_transaction_inmem" class="en__field__label en__field__label--item">This gift is in honor of / in memory of (optional)</label>
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        <div class="en__field en__field--select en__field--841591 en__field--othamt3 en__mandatory en__hidden">
          <label for="en__field_transaction_othamt3" class="en__field__label" style="">Is this in honor of or in memory of?</label>
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        <div class="en__field en__field--text en__field--841585 en__field--infname en__hidden">
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        <div class="en__field en__field--select en__field--841575 en__field--infreg en__hidden">
          <label for="en__field_transaction_infreg" class="en__field__label" style="">Notification Recipient State</label>
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              <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>
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              <option value="NH">New Hampshire</option>
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              <option value="OK">Oklahoma</option>
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              <label for="en__field_transaction_othamt1" class="en__field__label en__field__label--item">I am making a gift on behalf of my company</label>
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        <div class="en__submit"><button style="">Proceed to Pay</button></div>
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  <input type="hidden" name="doublethedonation_key" class="en__field__input en__field__input--hidden" value="fqw9ve0qgsPKJ4B4">
</form>

Text Content

DOUBLE YOUR DONATION FOR EPILEPSY CARE, ADVOCACY, RESEARCH AND EDUCATION.
$50.00
$35=$70
$50=$100
$100=$200
$250=$500
$500=$1,000
other

Make this a monthly donation
Payment Currency

Email Address for Your Electronic Receipt


Many companies sponsor matching gift programs that increase the impact of your
gift. See if your company will match your donation! (Optional)


This gift is in honor of / in memory of (optional)
Is this in honor of or in memory of?
In Honor Of In Memory Of
Honoree Name

Notification Recipient Name

Recipient E-mail Address

Notification Recipient Address

Notification Recipient City

Notification Recipient State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware
District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas
Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi
Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York
North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South
Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West
Virginia Wisconsin Wyoming
Notification Recipient Zip Code

Special Message (optional)

I am making a gift on behalf of my company
Company name

Proceed to Pay



© 2021 Epilepsy Foundation®, is a non-profit organization with a 501(c)(3)
tax-exempt status.

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CONTACT US

Headquarters Address: Epilepsy Foundation
3540 Crain Highway Ste 675, Bowie, MD 20716

Phone: 1-800-332-1000

Email: contactus@efa.org


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