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Thank you for helping to safeguard the well-being of our families, friends and neighbors.</p> <p>If you’d like to make a gift to Windemere Nursing & Rehabilitation Center, <a href="/windemere/">please click here</a>.</p> </div> </div> </div> </div> <div class="image-banner__image"> <picture>  <source sizes="100vw" media="(min-width:1225px)" srcset="https://giving.mvhospital.org/wp-content/uploads/2020/12/FINALS-0001-scaled-1.png"/> <img alt="Martha's Vineyard Hospital entrance" src="https://giving.mvhospital.org/wp-content/uploads/2020/12/FINALS-0001-scaled-1.png" /></picture> </div> </div> </div> <div id="content" class="site-content container"> <div class="row"> <div class="iw_columns col-lg-12"> <div id="primary" class="content-area"> <main id="main" class="site-main"> <article id="post-38" class="post-38 page type-page status-publish has-post-thumbnail hentry"> <div class="entry-content"> <div class='gf_browser_ie gf_browser_ie7 gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_9' style='display:none'><div id='gf_9' class='gform_anchor' tabindex='-1'></div><form method='post' enctype='multipart/form-data' target='gform_ajax_frame_9' id='gform_9' action='/#gf_9' data-formid='9' novalidate> <div class='gform-body gform_body'><div id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_9_19" class="gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_19" ><h3 class="gsection_title">Gift Information</h3></div><fieldset id="field_9_20" class="gfield gfield--type-radio gfield--type-choice gfield--width-full donation_buttons gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_20" ><legend class='gfield_label gform-field-label' >Gift Amount<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_20'> <div class='gchoice gchoice_9_20_0'> <input class='gfield-choice-input' name='input_20' type='radio' value='500' id='choice_9_20_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_9_20_0' id='label_9_20_0' class='gform-field-label gform-field-label--type-inline'>$500</label> </div> <div class='gchoice gchoice_9_20_1'> <input class='gfield-choice-input' name='input_20' type='radio' value='1000' id='choice_9_20_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_9_20_1' id='label_9_20_1' class='gform-field-label gform-field-label--type-inline'>$1,000</label> </div> <div class='gchoice gchoice_9_20_2'> <input class='gfield-choice-input' name='input_20' type='radio' value='5000' id='choice_9_20_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_9_20_2' id='label_9_20_2' class='gform-field-label gform-field-label--type-inline'>$5,000</label> </div> <div class='gchoice gchoice_9_20_3'> <input class='gfield-choice-input' name='input_20' type='radio' value='10000' id='choice_9_20_3' onchange='gformToggleRadioOther( this )' /> <label for='choice_9_20_3' id='label_9_20_3' class='gform-field-label gform-field-label--type-inline'>$10,000</label> </div> <div class='gchoice gchoice_9_20_4'> <input class='gfield-choice-input' name='input_20' type='radio' value='25000' id='choice_9_20_4' onchange='gformToggleRadioOther( this )' /> <label for='choice_9_20_4' id='label_9_20_4' class='gform-field-label gform-field-label--type-inline'>$25,000</label> </div> <div class='gchoice gchoice_9_20_5'> <input class='gfield-choice-input' name='input_20' type='radio' value='other' id='choice_9_20_5' onchange='gformToggleRadioOther( this )' /> <label for='choice_9_20_5' id='label_9_20_5' class='gform-field-label gform-field-label--type-inline'>Other</label> </div></div></div></fieldset><div id="field_9_21" class="gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_21" ><label class='gfield_label gform-field-label' for='input_9_21'>Other Amount<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label><div class='ginput_container ginput_container_number'><input name='input_21' id='input_9_21' type='text' step='any' min='5' value='' class='medium' aria-required="true" aria-invalid="false" aria-describedby="gfield_instruction_9_21" /><div class='gfield_description instruction ' id='gfield_instruction_9_21'>Please enter a number greater than or equal to <strong>5</strong>.</div></div></div><fieldset id="field_9_22" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-full hide-monthly field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_9_22" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Frequency - Monthly</legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_22'><div class='gchoice gchoice_9_22_1'> <input class='gfield-choice-input' name='input_22.1' type='checkbox' value='true' id='choice_9_22_1' /> <label for='choice_9_22_1' id='label_9_22_1' class='gform-field-label gform-field-label--type-inline'>Make this a monthly donation</label> </div></div></div></fieldset><fieldset id="field_9_23" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-full hide-annual field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_9_23" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Frequency - Annual</legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_23'><div class='gchoice gchoice_9_23_1'> <input class='gfield-choice-input' name='input_23.1' type='checkbox' value='true' id='choice_9_23_1' /> <label for='choice_9_23_1' id='label_9_23_1' class='gform-field-label gform-field-label--type-inline'>Make this an annual donation</label> </div></div></div></fieldset><div id="field_9_24" class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full hidden-sm hidden-md hidden-lg gfield_price gfield_price_9_24 gfield_product_9_24 gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_24" ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_9_24_1'>Donation Amount</label><div class='ginput_container ginput_container_product_calculation'> <input type='hidden' name='input_24.1' value='Donation Amount' class='gform_hidden' /> <div id='ginput_product_price_9_24' class='ginput_product_price_wrapper'> <span class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:</span> <span class='gform-field-label gform-field-label--type-sub-large ginput_product_price' id='input_9_24'>$0.00</span> </div> <input type='hidden' name='input_24.2' id='ginput_base_price_9_24' class='gform_hidden' value='$0.00'/> <input type='hidden' name='input_24.3' value='1' class='ginput_quantity_9_24 gform_hidden' /> </div></div><div id="field_9_25" class="gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_25" ><label class='gfield_label gform-field-label' for='input_9_25'>Designation<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label><div class='ginput_container ginput_container_select'><select name='input_25' id='input_9_25' class='large gfield_select' aria-required="true" aria-invalid="false" ><option value='' selected='selected' class='gf_placeholder'>Please Select</option><option value='MV8360-AF' >Annual Fund</option><option value='Behavioral Health' >Behavioral Health</option><option value='Cardiology' >Cardiology</option><option value='Dialysis' >Dialysis</option><option value='Emergency Care' >Emergency Care</option><option value='099208' >Golf Tournament</option><option value='Imaging' >Imaging</option><option value='Infusion & Oncology' >Infusion & Oncology</option><option value='Inpatient Care' >Inpatient Care</option><option value='Laboratory' >Laboratory</option><option value='Maternity' >Maternity</option><option value='Nursing' >Nursing</option><option value='Primary Care' >Primary Care</option><option value='Rehab & Wellness' >Rehab & Wellness</option><option value='099207' >Sullivan 5K Run/Walk</option><option value='Surgery' >Surgery</option><option value='Women's Health' >Women's Health</option><option value='098303' >Workforce Housing</option><option value='Other' >Other</option></select></div></div><div id="field_9_47" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_47" ><label class='gfield_label gform-field-label' for='input_9_47'>Other Designation</label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_9_47' type='text' value='' class='medium' aria-invalid="false" /> </div></div><div id="field_9_26" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_9_26" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_9_26'>Designation</label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_9_26' type='text' value='' class='large' aria-invalid="false" /> </div></div><div id="field_9_27" class="gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_27" ><h3 class="gsection_title">Tribute Information</h3></div><fieldset id="field_9_28" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_28" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Tribute</legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_28'><div class='gchoice gchoice_9_28_1'> <input class='gfield-choice-input' name='input_28.1' type='checkbox' value='true' id='choice_9_28_1' /> <label for='choice_9_28_1' id='label_9_28_1' class='gform-field-label gform-field-label--type-inline'>I am making this gift in honor or memory of someone</label> </div></div></div></fieldset><div id="field_9_29" class="gfield gfield--type-select gfield--width-full gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_29" ><label class='gfield_label gform-field-label' for='input_9_29'>Tribute Type<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label><div class='ginput_container ginput_container_select'><select name='input_29' id='input_9_29' class='large gfield_select' aria-required="true" aria-invalid="false" ><option value='honor' >in honor of</option><option value='memory' >in memory of</option></select></div></div><div id="field_9_30" class="gfield gfield--type-text gfield--width-full gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_30" ><label class='gfield_label gform-field-label' for='input_9_30'>Name<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_9_30' type='text' value='' class='large' aria-required="true" aria-invalid="false" /> </div></div><fieldset id="field_9_31" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_9_31" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Tribute Notify</legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_31'><div class='gchoice gchoice_9_31_1'> <input class='gfield-choice-input' name='input_31.1' type='checkbox' value='true' id='choice_9_31_1' /> <label for='choice_9_31_1' id='label_9_31_1' class='gform-field-label gform-field-label--type-inline'>Please send notification of my gift</label> </div></div></div></fieldset><div id="field_9_32" class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_32" ><p>Enter a name and a mailing or email address and we'll share a notice about your donation.</p></div><div id="field_9_33" class="gfield gfield--type-text gfield--width-full gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_33" ><label class='gfield_label gform-field-label' for='input_9_33'>Name of Person to Nofity</label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_9_33' type='text' value='' class='large' aria-invalid="false" /> </div></div><fieldset id="field_9_34" class="gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_34" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address of Person to Notify</legend> <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_9_34' > <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_9_34_1_container' > <input type='text' name='input_34.1' id='input_9_34_1' value='' aria-required='false' /> <label for='input_9_34_1' id='input_9_34_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address</label> </span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_9_34_3_container' > <input type='text' name='input_34.3' id='input_9_34_3' value='' aria-required='false' /> <label for='input_9_34_3' id='input_9_34_3_label' class='gform-field-label gform-field-label--type-sub '>City</label> </span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_9_34_4_container' > <input type='text' name='input_34.4' id='input_9_34_4' value='' aria-required='false' /> <label for='input_9_34_4' id='input_9_34_4_label' class='gform-field-label gform-field-label--type-sub '>State / Province / Region</label> </span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_9_34_5_container' > <input type='text' name='input_34.5' id='input_9_34_5' value='' aria-required='false' /> <label for='input_9_34_5' id='input_9_34_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP / Postal Code</label> </span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_9_34_6_container' > <select name='input_34.6' id='input_9_34_6' aria-required='false' ><option value='' ></option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Anguilla' >Anguilla</option><option value='Antarctica' >Antarctica</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Aruba' >Aruba</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Bouvet Island' >Bouvet Island</option><option value='Brazil' >Brazil</option><option value='British Indian Ocean Territory' >British Indian Ocean Territory</option><option value='Brunei Darussalam' >Brunei Darussalam</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cabo Verde' >Cabo Verde</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo' >Congo</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Cura莽ao' >Cura莽ao</option><option value='Cyprus' >Cyprus</option><option value='Czechia' >Czechia</option><option value='C么te d'Ivoire' >C么te d'Ivoire</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini' >Eswatini</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Korea, Democratic People's Republic of' >Korea, Democratic People's Republic of</option><option value='Korea, Republic of' >Korea, Republic of</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People's Democratic Republic' >Lao People's Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macao' >Macao</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Macedonia' >North Macedonia</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russian Federation' >Russian Federation</option><option value='Rwanda' >Rwanda</option><option value='R茅union' >R茅union</option><option value='Saint Barth茅lemy' >Saint Barth茅lemy</option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria Arab Republic' >Syria Arab Republic</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' >Tuvalu</option><option value='T眉rkiye' >T眉rkiye</option><option value='US Minor Outlying Islands' >US Minor Outlying Islands</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' selected='selected'>United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Viet Nam' >Viet Nam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option><option value='脜land Islands' >脜land Islands</option></select> <label for='input_9_34_6' id='input_9_34_6_label' class='gform-field-label gform-field-label--type-sub '>Country</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></fieldset><div id="field_9_35" class="gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_35" ><label class='gfield_label gform-field-label' for='input_9_35'>Email of Person to Notify</label><div class='ginput_container ginput_container_email'> <input name='input_35' id='input_9_35' type='email' value='' class='medium' aria-invalid="false" /> </div></div><div id="field_9_36" class="gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_36" ><h3 class="gsection_title">Your Information</h3></div><fieldset id="field_9_37" class="gfield gfield--type-creditcard gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_37" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Credit Card Details<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend><div class='ginput_complex ginput_container ginput_container_creditcard gform-grid-row' id='input_9_37'><span class='ginput_full gform-grid-col' id='input_9_37_1_container' > <div class='gform_card_icon_container'><div class='gform_card_icon gform_card_icon_amex' >American Express</div><div class='gform_card_icon gform_card_icon_discover' >Discover</div><div class='gform_card_icon gform_card_icon_mastercard' >MasterCard</div><div class='gform_card_icon gform_card_icon_visa' >Visa</div><span class='screen-reader-text' id='field_9_37_supported_creditcards'>Supported Credit Cards: American Express, Discover, MasterCard, Visa</span></div> <input type='text' name='input_37.1' id='input_9_37_1' value='' onchange='gformMatchCard("input_9_37_1");' onkeyup='gformMatchCard("input_9_37_1");' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed' aria-required='true' /> <label for='input_9_37_1' id='input_9_37_1_label' class='gform-field-label gform-field-label--type-sub '>Card Number</label> </span><span class='ginput_full ginput_cardextras gform-grid-col gform-grid-row' id='input_9_37_2_container'> <fieldset class='ginput_cardinfo_left gform-grid-col' id='input_9_37_2_cardinfo_left'> <legend class='gform-field-label gform-field-label--type-sub '>Expiration Date</legend> <span class='ginput_card_expiration_container ginput_card_field gform-grid-row'> <span class='ginput_card_expiration_month_container gform-grid-col'> <label for='input_9_37_2_month' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month</label> <select name='input_37.2[]' id='input_9_37_2_month' class='ginput_card_expiration ginput_card_expiration_month' aria-required='true' > <option value=''>Month</option><option value='1' >01</option><option value='2' >02</option><option value='3' >03</option><option value='4' >04</option><option value='5' >05</option><option value='6' >06</option><option value='7' >07</option><option value='8' >08</option><option value='9' >09</option><option value='10' >10</option><option value='11' >11</option><option value='12' >12</option> </select> </span> <span class='ginput_card_expiration_year_container gform-grid-col'> <label for='input_9_37_2_year' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year</label> <select name='input_37.2[]' id='input_9_37_2_year' class='ginput_card_expiration ginput_card_expiration_year' aria-required='true' > <option value=''>Year</option><option value='2024' >2024</option><option value='2025' >2025</option><option value='2026' >2026</option><option value='2027' >2027</option><option value='2028' >2028</option><option value='2029' >2029</option><option value='2030' >2030</option><option value='2031' >2031</option><option value='2032' >2032</option><option value='2033' >2033</option><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><option value='2040' >2040</option><option value='2041' >2041</option><option value='2042' >2042</option><option value='2043' >2043</option> </select> </span> </span> </fieldset><span class='ginput_cardinfo_right gform-grid-col' id='input_9_37_2_cardinfo_right'> <input type='text' name='input_37.3' id='input_9_37_3' class='ginput_card_security_code' value='' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed' aria-required='true' /> <span class='ginput_card_security_code_icon'> </span> <label for='input_9_37_3' class='gform-field-label gform-field-label--type-sub '>Security Code</label> </span> </span><span class='ginput_full gform-grid-col' id='input_9_37_5_container'> <input type='text' name='input_37.5' id='input_9_37_5' value='' aria-required='false' /> <label for='input_9_37_5' id='input_9_37_5_label' class='gform-field-label gform-field-label--type-sub '>Cardholder Name</label> </span> </div></fieldset><div id="field_9_38" class="gfield gfield--type-select gfield--width-full left title field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_38" ><label class='gfield_label gform-field-label' for='input_9_38'>Title</label><div class='ginput_container ginput_container_select'><select name='input_38' id='input_9_38' class='medium gfield_select' aria-invalid="false" ><option value='' selected='selected' class='gf_placeholder'>Please Select</option><option value='Dr.' >Dr.</option><option value='Mr.' >Mr.</option><option value='Mrs.' >Mrs.</option><option value='Ms.' >Ms.</option><option value='Mx.' >Mx.</option></select></div></div><fieldset id="field_9_39" class="gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_39" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_9_39'> <span id='input_9_39_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' > <input type='text' name='input_39.3' id='input_9_39_3' value='' aria-required='true' /> <label for='input_9_39_3' class='gform-field-label gform-field-label--type-sub '>First</label> </span> <span id='input_9_39_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' > <input type='text' name='input_39.6' id='input_9_39_6' value='' aria-required='true' /> <label for='input_9_39_6' class='gform-field-label gform-field-label--type-sub '>Last</label> </span> </div></fieldset><div id="field_9_40" class="gfield gfield--type-email gfield--width-full left email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_40" ><label class='gfield_label gform-field-label' for='input_9_40'>Email<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label><div class='ginput_container ginput_container_email'> <input name='input_40' id='input_9_40' type='email' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></div><fieldset id="field_9_41" class="gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_41" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend> <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_9_41' > <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_9_41_1_container' > <input type='text' name='input_41.1' id='input_9_41_1' value='' aria-required='true' /> <label for='input_9_41_1' id='input_9_41_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address</label> </span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_9_41_3_container' > <input type='text' name='input_41.3' id='input_9_41_3' value='' aria-required='true' /> <label for='input_9_41_3' id='input_9_41_3_label' class='gform-field-label gform-field-label--type-sub '>City</label> </span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_9_41_4_container' > <input type='text' name='input_41.4' id='input_9_41_4' value='' aria-required='true' /> <label for='input_9_41_4' id='input_9_41_4_label' class='gform-field-label gform-field-label--type-sub '>State / Province / Region</label> </span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_9_41_5_container' > <input type='text' name='input_41.5' id='input_9_41_5' value='' aria-required='true' /> <label for='input_9_41_5' id='input_9_41_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP / Postal Code</label> </span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_9_41_6_container' > <select name='input_41.6' id='input_9_41_6' aria-required='true' ><option value='' ></option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Anguilla' >Anguilla</option><option value='Antarctica' >Antarctica</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Aruba' >Aruba</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Bouvet Island' >Bouvet Island</option><option value='Brazil' >Brazil</option><option value='British Indian Ocean Territory' >British Indian Ocean Territory</option><option value='Brunei Darussalam' >Brunei Darussalam</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cabo Verde' >Cabo Verde</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo' >Congo</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Cura莽ao' >Cura莽ao</option><option value='Cyprus' >Cyprus</option><option value='Czechia' >Czechia</option><option value='C么te d'Ivoire' >C么te d'Ivoire</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini' >Eswatini</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Korea, Democratic People's Republic of' >Korea, Democratic People's Republic of</option><option value='Korea, Republic of' >Korea, Republic of</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People's Democratic Republic' >Lao People's Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macao' >Macao</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Macedonia' >North Macedonia</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russian Federation' >Russian Federation</option><option value='Rwanda' >Rwanda</option><option value='R茅union' >R茅union</option><option value='Saint Barth茅lemy' >Saint Barth茅lemy</option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria Arab Republic' >Syria Arab Republic</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' >Tuvalu</option><option value='T眉rkiye' >T眉rkiye</option><option value='US Minor Outlying Islands' >US Minor Outlying Islands</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' selected='selected'>United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Viet Nam' >Viet Nam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option><option value='脜land Islands' >脜land Islands</option></select> <label for='input_9_41_6' id='input_9_41_6_label' class='gform-field-label gform-field-label--type-sub '>Country</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></fieldset><div id="field_9_42" class="gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_42" ><h3 class="gsection_title">Additional Details</h3></div><fieldset id="field_9_48" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_9_48" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Island Address is Different</legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_48'><div class='gchoice gchoice_9_48_1'> <input class='gfield-choice-input' name='input_48.1' type='checkbox' value='My island address is different from my billing address' id='choice_9_48_1' /> <label for='choice_9_48_1' id='label_9_48_1' class='gform-field-label gform-field-label--type-inline'>My island address is different from my billing address</label> </div></div></div></fieldset><fieldset id="field_9_49" class="gfield gfield--type-address gfield--width-full island-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_49" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Island Address</legend> <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_9_49' > <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_9_49_1_container' > <input type='text' name='input_49.1' id='input_9_49_1' value='' aria-required='false' /> <label for='input_9_49_1' id='input_9_49_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address</label> </span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_9_49_2_container' > <input type='text' name='input_49.2' id='input_9_49_2' value='' aria-required='false' /> <label for='input_9_49_2' id='input_9_49_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2</label> </span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_9_49_3_container' > <input type='text' name='input_49.3' id='input_9_49_3' value='' aria-required='false' /> <label for='input_9_49_3' id='input_9_49_3_label' class='gform-field-label gform-field-label--type-sub '>City</label> </span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_9_49_4_container' > <input type='text' name='input_49.4' id='input_9_49_4' value='' aria-required='false' /> <label for='input_9_49_4' id='input_9_49_4_label' class='gform-field-label gform-field-label--type-sub '>State / Province / Region</label> </span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_9_49_5_container' > <input type='text' name='input_49.5' id='input_9_49_5' value='' aria-required='false' /> <label for='input_9_49_5' id='input_9_49_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP / Postal Code</label> </span><input type='hidden' class='gform_hidden' name='input_49.6' id='input_9_49_6' value='' /> <div class='gf_clear gf_clear_complex'></div> </div></fieldset><fieldset id="field_9_43" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_9_43" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Anonymous</legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_43'><div class='gchoice gchoice_9_43_1'> <input class='gfield-choice-input' name='input_43.1' type='checkbox' value='true' id='choice_9_43_1' /> <label for='choice_9_43_1' id='label_9_43_1' class='gform-field-label gform-field-label--type-inline'>I am making this gift anonymously</label> </div></div></div></fieldset><fieldset id="field_9_44" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_9_44" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Corporate</legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_44'><div class='gchoice gchoice_9_44_1'> <input class='gfield-choice-input' name='input_44.1' type='checkbox' value='Y' id='choice_9_44_1' /> <label for='choice_9_44_1' id='label_9_44_1' class='gform-field-label gform-field-label--type-inline'>This is a donation from a corporation</label> </div></div></div></fieldset><div id="field_9_45" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_45" ><label class='gfield_label gform-field-label' for='input_9_45'>Company Name<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_9_45' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></div><div id="field_9_46" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_46" ><label class='gfield_label gform-field-label' for='input_9_46'>Comments</label><div class='ginput_container ginput_container_textarea'><textarea name='input_46' id='input_9_46' class='textarea medium' aria-invalid="false" rows='10' cols='50'></textarea></div></div><div id="field_9_1" class="gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_9_1" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><h3 class="gsection_title">Admin</h3></div><div id="field_9_2" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_9_2" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_9_2'>Atlas Fund</label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_9_2' type='text' value='' class='medium' aria-invalid="false" /> </div></div><div id="field_9_4" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_9_4" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_9_4'>Atlas Appeal</label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_9_4' type='text' value='Web/Online Donation' class='medium' aria-invalid="false" /> </div></div><div id="field_9_5" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_9_5" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_9_5'>Atlas Package</label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_9_5' type='text' value='' class='medium' aria-invalid="false" /> </div></div><div id="field_9_12" class="gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_9_12" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><h3 class="gsection_title">Page Info</h3></div><div id="field_9_6" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_9_6" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_9_6'>Referer</label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_9_6' type='text' value='' class='medium' aria-invalid="false" /> </div></div><div id="field_9_7" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_9_7" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_9_7'>Embed URL</label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_9_7' type='text' value='https://giving.mvhospital.org/' class='medium' aria-invalid="false" /> </div></div><div id="field_9_8" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_9_8" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_9_8'>Page Title</label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_9_8' type='text' value='Giving' class='medium' aria-invalid="false" /> </div></div><div id="field_9_13" class="gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_9_13" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><h3 class="gsection_title">Form Controllers</h3></div><div id="field_9_9" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_9_9" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_9_9'>Recurring Controller</label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_9_9' type='text' value='true' class='medium' aria-invalid="false" /> </div></div><div id="field_9_10" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_9_10" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_9_10'>Tribute Controller</label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_9_10' type='text' value='true' class='medium' aria-invalid="false" /> </div></div><div id="field_9_11" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_9_11" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_9_11'>Anonymous Controller</label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_9_11' type='text' value='true' class='medium' aria-invalid="false" /> </div></div><div id="field_9_14" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_9_14" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_9_14'>Corporate Controller</label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_9_14' type='text' value='true' class='large' aria-invalid="false" /> </div></div><div id="field_9_15" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_9_15" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_9_15'>Designation Controller</label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_9_15' type='text' value='true' class='large' aria-invalid="false" /> </div></div><div id="field_9_16" class="gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_9_16" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><h3 class="gsection_title">Authorize.net</h3></div><div 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