CINXE.COM

<!DOCTYPE html> <html> <head> <base href="https://secure.phoenixchildrensfoundation.org/site/" /> <title> Support Phoenix Children's - Phoenix Children's Foundation </title> <meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" /> <meta http-equiv="Content-Script-Type" content="text/javascript" /> <meta name="Keywords" content=" " /> <meta name="Description" content="" /> <meta name="Robots" content="index, follow" /> <script type="text/javascript" src="../yui3/yui/yui-min.js"></script><noscript> </noscript> <script type="text/javascript" src="../js/convio/modules.js?version=2.9.2"></script><noscript> </noscript> <script type="text/javascript"> var Y = YUI({base: '../yui3/', insertBefore: 'yui_marker_loader_css', // insert all YUI module css before customstyle so it can be overridden debug: false, modules: getModules('../', 'convio', true, false)}); </script><noscript> </noscript> <script type="text/javascript" src="../js/utils.js"></script><noscript> </noscript> <script type="text/javascript" src="../js/obs_comp_rollup.js"></script><noscript> </noscript> <link href="../css/themes/default.css" rel="stylesheet" type="text/css" /> <link href="../css/themes/alphacube.css" rel="stylesheet" type="text/css"/> <link href="../css/UserGlobalStyle.css" rel="stylesheet" type="text/css" /> <link href="../css/UserIEStyle.css" rel="stylesheet" type="text/css" /> <link href="../css/responsive/ResponsiveBase.css" rel="stylesheet" type="text/css" /> <link href="../css/responsive/DonFormResponsive.css" rel="stylesheet" type="text/css" /> <link href="../css/FormComponentsBehavior.css" rel="stylesheet" type="text/css" /> <script type="text/javascript" src="../js/FormComponentsBehavior.js"></script><noscript> </noscript> <script type="text/javascript" src="../js/don_level_elements.js"></script><noscript> </noscript> <script type="text/javascript" src="../js/don_premium_elements.js"></script><noscript> </noscript> <script type="text/javascript" src="../js/donations2.js"></script><noscript> </noscript> <link rel="stylesheet" type="text/css" id="yui_marker_loader_css" /> <link href="../css/CustomStyle.css" rel="stylesheet" type="text/css" /> <link href="../css/CustomWysiwygStyle.css" rel="stylesheet" type="text/css" /> <meta name="CnvHeaderVersion" content="v5.0" /> <meta charset="UTF-8"> <meta name="viewport" content="width='device-width', initial-scale=1.0"> <script src="https://code.jquery.com/jquery-3.7.1.min.js" integrity="sha256-/JqT3SQfawRcv/BIHPThkBvs0OEvtFFmqPF/lYI/Cxo=" crossorigin="anonymous"></script> <style type="text/css"> .donSurvey {margin-bottom:20px;overflow:hidden;} .donSurvey span {font-size:22px;margin-bottom:20px;} .donSurvey li input {vertical-align:initial; display: inline; margin-right: 20px;} .donSurvey li label, .donSurvey p.bigger {font-size:22px;font-family: "Sorts Mill Goudy","Whitney-Book","Open Sans Condensed", sans-serif !important; } .donSurvey .red { color: #E4002B; font-weight: bold; } .donSurvey li textarea { display: block; } .donSurvey .Button {margin-top:10px;cursor: pointer; font-family: "Open Sans","Montserrat", sans-serif !important; width: 100%; max-width: 250px; padding: 2% 7%; margin-bottom: 10px; text-align: center; background: #E4002B; color: #fff; font-weight: bold; font-size: 1.6em; border-radius: 6px; } .donSurvey ul { list-style-type: none; } .surveyEmail {display:none;} P, LI, OL, UL, TABLE, TR, TH, TD, .Explicit { font-family: 'Roboto', sans-serif; font-size: 20px; line-height: 26px; } .donSurvey li input { vertical-align: initial; display: inline; margin-right: 20px; } .donSurvey li label{ padding-top:0px !important; } .donSurvey input[type="checkbox"] { width: 20px !important; height: 20px !important; display: inline-block; margin: 0 10px 0 0; } </style>  <link rel="stylesheet" href="https://mwdagency.com/test/pch/css/eft-dpo.css">       <script type="text/javascript"> window.dataLayer = window.dataLayer || []; function donationTracker() { var giftAmount = "($0.01)"; var giftAmountUpdated = giftAmount.replace("$", "").replace(/[,]/g, ""); var donationFormName = "2024 Year End - Main"; var donationFormNameUpdated = donationFormName.replace("'", ""); dataLayer.push({ 'event': 'donationTransaction', 'ecommerce': { 'purchase': { 'actionField': { 'id': '0', 'affiliation': '4600', 'revenue': giftAmountUpdated }, 'products': [{ 'id': '12649', 'name': donationFormNameUpdated, 'price': giftAmountUpdated, 'category': "Donations", 'brand': 'PCHF', 'quantity': 1 }] } } }); } // end donationTracker() function function eCommerceTracker() { var customURL = window.location.href; customURL = customURL.replace("&", "&"); window.history.pushState("PCHF", "PCHF", customURL); var storeId = ""; var personalGift = $('p#additional_donation').text().replace("$", "").replace(/[,]/g, "").trim(); var trackingCode = $('span#tracking_code').text().trim(); var numItems = $("div.ShoppingCart [class*='ShoppingCartRow']").length; var eQuantity = []; var transTotal = []; var itemName = []; $("div.ShoppingCart [class*='ShoppingCartRow']").each(function() { eQuantity.push($(this).find("div.quantity-column").text().trim()); itemName.push($(this).find("span.CartItemName").text().replace("'", "")); transTotal.push($(this).find("div.price-column").text().replace("$", "").replace(/[,]/g, "").trim()); }); var eTotal = $("div.ShoppingCart div.total-price-column:last").text().replace("$", "").replace(/[,]/g, "").trim(); var prodsObject = []; for (var i = 0; i < numItems; i++) { if (eQuantity[i] > 0) { prodsObject.push({ name: itemName[i], category: 'eCommerce', price: transTotal[i] / eQuantity[i], brand: 'PCHF', quantity: eQuantity[i] }); } } //Adding personal gift if present if (personalGift) { (prodsObject).push({ 'name': 'Personal Gift', 'category': 'Upsell', 'price': personalGift, 'brand': 'PCHF', 'quantity': '1' }); } dataLayer.push({ 'event': 'ecomTransaction', 'ecommerce': { 'purchase': { 'actionField': { 'id': trackingCode, 'affiliation': storeId, 'revenue': eTotal }, 'products': prodsObject } } }); } // end eCommerceTracker() function function teamraiserTracker() { var regamt = $('span#total_amt').text(); var regtrk = $('span#tracking_code_value').text(); var trName = ""; var trNameTrimmed = trName.replace("'", ""); var regamtUpdated = regamt.replace("$", "").replace(/[,]/g, ""); dataLayer.push({ 'event': 'teamraiserTransaction', 'ecommerce': { 'purchase': { 'actionField': { 'id': regtrk, 'affiliation': '', 'revenue': regamtUpdated }, 'products': [{ 'id': '', 'name': trNameTrimmed, 'price': regamtUpdated, 'category': "Teamraiser", 'brand': 'PCHF', 'quantity': 1 }] } } }); } // end teamraiserTracker() function function ticketedTracker() { $("tr.lc_Totals td:nth-child(4)").addClass("total-price"); var totalprice = $('.total-price p').text(); var totalpriceUpdated = totalprice.replace("$", "").replace(/[,]/g, ""); $("tr.lc_Totals td:nth-child(3)").addClass("total-quantity"); var ticketquantity = $('.total-quantity p').text(); dataLayer.push({ 'event': 'ticketedTransaction', 'ecommerce': { 'purchase': { 'actionField': { 'id': '', 'affiliation': '', 'revenue': totalpriceUpdated }, 'products': [{ 'id': '', 'name': 'Ticket Event', 'price': totalpriceUpdated, 'category': "Tickets", 'brand': 'PCHF', 'quantity': ticketquantity }] } } }); } // end ticketedTracker() function </script> <script type="text/javascript"> (function(a, s, y, n, c, h, i, d, e) { s.className += ' ' + y; h.start = 1 * new Date; h.end = i = function() { s.className = s.className.replace(RegExp(' ?' + y), '') }; (a[n] = a[n] || []).hide = h; setTimeout(function() { i(); h.end = null }, c); h.timeout = c; })(window, document.documentElement, 'async-hide', 'dataLayer', 4000, { 'GTM-NPFWKP5': true }); </script>  <script type="text/javascript"> (function(w, d, s, l, i) { w[l] = w[l] || []; w[l].push({ 'gtm.start': new Date().getTime(), event: 'gtm.js' }); var f = d.getElementsByTagName(s)[0], j = d.createElement(s), dl = l != 'dataLayer' ? '&l=' + l : ''; j.async = true; j.src = 'https://www.googletagmanager.com/gtm.js?id=' + i + dl; f.parentNode.insertBefore(j, f); })(window, document, 'script', 'dataLayer', 'GTM-NPFWKP5'); </script> <script type="text/javascript"> Y.use('jquery-noconflict', function() { jQuery(function($) { $(document).ready(function() { //checks for Google Analytics events if ((window.location.href.indexOf("7691") > -1) || (window.location.href.indexOf("8129") > -1) || (window.location.href.indexOf("7752") > -1) || (window.location.href.indexOf("8127") > -1)) { // only on AB Test pages abTestGoalTracker(); } //checks for the donation form completion page if (window.location.href.indexOf("donation=completed") > -1) { //calling the donation tracker function. donationTracker(); } //ecommerce completion page if (window.location.href.indexOf("CONFIRMATION=true") > -1) { //calling the ecommerce tracker eCommerceTracker(); } //teamraiser completion page if (window.location.href.indexOf("pg=rthanks") > -1) { //calling the teamraiser tracker teamraiserTracker(); } //calendar of events completion page if (window.location.href.indexOf("view=confirm") > -1) { //calling the calendar of events tracker ticketedTracker(); } }); }); }); </script>       </head> <body >  <noscript><iframe src="https://www.googletagmanager.com/ns.html?id=GTM-NPFWKP5" height="0" width="0" style="display:none;visibility:hidden"></iframe></noscript>  <header> <a href="https://phoenixchildrensfoundation.org/?_gl=1*1vie9dp*_gcl_au*MTEwMDk2NzU0MC4xNzE0MTYxNTY2*_ga*OTg2NTEzMDMxLjE3MTQxNjE1NjY.*_ga_N6P4P7MXYN*MTcxNDE2NzQ2My4yLjAuMTcxNDE2ODAxOS42MC4wLjA."> <img src="../images/content/pagebuilder/PC-Logo_RGB_KO-White_Horz_4x.png" alt="Phoenix Children's Foundation" style="width: 100%; max-width: 255px;"> </a> </header> <section id="main"> <form name="process" id="ProcessForm" action="https://secure.phoenixchildrensfoundation.org/site/Donation2" method="post" onsubmit="return checkDoubleClick();" > <div class="donation-form-container responsive"> <script type="text/javascript">  </script> <div class="donation-form-content"> <script> document.body.addEventListener("keypress", function(event) { if (event.keyCode === 13) { event.preventDefault(); var button = document.getElementById("pstep_finish"); if (!button) { button = document.getElementById("pstep_next"); } if (!button) { button = document.getElementById("pstep_finish_validate"); } if(button) { button.click(); } } }); </script> <input type="hidden" name="user_donation_amt" id="user_donation_amt" value="" /> <input type="hidden" name="company_min_matching_amt" id="company_min_matching_amt" value="" /> <input type="hidden" name="currency_locale" id="currency_locale" value="en_US" /> <input type="hidden" name="user_additional_amount" id="user_additional_amount" value="" /> <input type="hidden" name="cc_available" id="cc_available" value="false" /> <input type="hidden" name="debit_available" id="debit_available" value="false" /> <input type="hidden" name="paypal_available" id="paypal_available" value="false" /> <input type="hidden" name="wallets_available" id="wallets_available" value="false" /> <input type="hidden" name="primary_color" id="primary_color" value="" /> <input type="hidden" name="application_name" id="application_name" value="Luminate" /> <input type="hidden" name="secondary_color" id="secondary_color" value="" /> <input type="hidden" name="font_color" id="font_color" value="" /> <input type="hidden" name="font_family" id="font_family" value="" /> <input type="hidden" name="secure_url" id="secure_url" value="https://secure.phoenixchildrensfoundation.org/site/" /> <input type="hidden" name="is_admin_app" id="is_admin_app" value="F" /> <input type="hidden" name="environment_id" id="environment_id" value="" /> <input type="hidden" name="merchant_account_configuration_id" id="merchant_account_configuration_id" value="" /> <input type="hidden" name="pco_javascript_location" id="pco_javascript_location" value="" /> <input type="hidden" name="pco_language_locale" id="pco_language_locale" value="en_US" /> <input type="hidden" name="pco_environment_zone" id="pco_environment_zone" value="p-usa01" /> <div class="form-row"> <div class="html-caption-container"> <div class="hero"><img src="https://phoenixchildrensfoundation.org/wp-content/uploads/2024/09/24_YE-Donation-Form-Headers_Iris-1_1920x800-1.png" alt="Iris in hospital bed" /></div> <span class="giftAmountLabel">Choose Your Gift Amount</span> <div class="gift-types"><label class="single"> <div>ONE-TIME</div> </label> <label class="monthly"> <div>MONTHLY</div> </label></div> </div> </div> <div id="level_standard_row"> <div class="don-standard-levels form-row"> <div class="levels-label"> </div> <div id="level_standard_row" class="form-row form-donation-level"> <div class="form-content"> <span class="field-required"></span> <span class="aural-only">Field Is Required</span> <span class="FormLabelText">Choose Your Gift Amount</span> <div class="donation-level-general-ask"> </div> <div class="donation-levels"> <div class="donation-level-container"> <div class="form-content"> <div class="donation-level-input-container form-input"> <div class="donation-level-label-input-container"> <input type="radio" name="level_standardexpanded" id="level_standardexpanded43091" value="43091" onclick="evalMatchingGift(''); updateDonorCoverAmount('');" /> </div> <label for="level_standardexpanded43091" onclick=""> <div class="donation-level-label-container"> $50 </div> </label> </div> <input type="hidden" name="level_standardexpandedsubmit" id="level_standard_43091expandedsubmit" value="true" /> </div> </div> <div class="donation-level-container"> <div class="form-content"> <div class="donation-level-input-container form-input"> <div class="donation-level-label-input-container"> <input type="radio" name="level_standardexpanded" id="level_standardexpanded43092" value="43092" checked="checked" onclick="evalMatchingGift(''); updateDonorCoverAmount('');" /> </div> <label for="level_standardexpanded43092" onclick=""> <div class="donation-level-label-container"> $100 </div> </label> </div> <input type="hidden" name="level_standardexpandedsubmit" id="level_standard_43092expandedsubmit" value="true" /> </div> </div> <div class="donation-level-container"> <div class="form-content"> <div class="donation-level-input-container form-input"> <div class="donation-level-label-input-container"> <input type="radio" name="level_standardexpanded" id="level_standardexpanded43093" value="43093" onclick="evalMatchingGift(''); updateDonorCoverAmount('');" /> </div> <label for="level_standardexpanded43093" onclick=""> <div class="donation-level-label-container"> $250 </div> </label> </div> <input type="hidden" name="level_standardexpandedsubmit" id="level_standard_43093expandedsubmit" value="true" /> </div> </div> <div class="donation-level-container"> <div class="form-content"> <div class="donation-level-input-container form-input"> <div class="donation-level-label-input-container"> <input type="radio" name="level_standardexpanded" id="level_standardexpanded43094" value="43094" onclick="evalMatchingGift(''); updateDonorCoverAmount('');" /> </div> <label for="level_standardexpanded43094" onclick=""> <div class="donation-level-label-container"> $500 </div> </label> </div> <input type="hidden" name="level_standardexpandedsubmit" id="level_standard_43094expandedsubmit" value="true" /> </div> </div> <div class="donation-level-container"> <div class="form-content"> <div class="donation-level-input-container form-input"> <div class="donation-level-label-input-container"> <input type="radio" name="level_standardexpanded" id="level_standardexpanded43095" value="43095" onclick="evalMatchingGift(''); updateDonorCoverAmount('');" /> </div> <label for="level_standardexpanded43095" onclick=""> <div class="donation-level-label-container"> $1,000 </div> </label> </div> <input type="hidden" name="level_standardexpandedsubmit" id="level_standard_43095expandedsubmit" value="true" /> </div> </div> <div class="donation-level-container"> <div class="form-content"> <div class="donation-level-input-container form-input"> <div class="donation-level-label-input-container"> <input type="radio" name="level_standardexpanded" id="level_standardexpanded43096" value="43096" onclick="evalMatchingGift(''); updateDonorCoverAmount('');" /> </div> <label for="level_standardexpanded43096" onclick=""> <div class="donation-level-label-container"> $5 </div> </label> </div> <input type="hidden" name="level_standardexpandedsubmit" id="level_standard_43096expandedsubmit" value="true" /> </div> </div> <div class="donation-level-container"> <div class="form-content"> <div class="donation-level-input-container form-input"> <div class="donation-level-label-input-container"> <input type="radio" name="level_standardexpanded" id="level_standardexpanded43097" value="43097" onclick="evalMatchingGift(''); updateDonorCoverAmount('');" /> </div> <label for="level_standardexpanded43097" onclick=""> <div class="donation-level-label-container"> $10 </div> </label> </div> <input type="hidden" name="level_standardexpandedsubmit" id="level_standard_43097expandedsubmit" value="true" /> </div> </div> <div class="donation-level-container"> <div class="form-content"> <div class="donation-level-input-container form-input"> <div class="donation-level-label-input-container"> <input type="radio" name="level_standardexpanded" id="level_standardexpanded43087" value="43087" onclick="evalMatchingGift(''); updateDonorCoverAmount('');" /> </div> <label for="level_standardexpanded43087" onclick=""> <div class="donation-level-label-container"> $25 </div> </label> </div> <input type="hidden" name="level_standardexpandedsubmit" id="level_standard_43087expandedsubmit" value="true" /> </div> </div> <div class="donation-level-container"> <div class="form-content"> <div class="donation-level-input-container form-input"> <div class="donation-level-label-input-container"> <input type="radio" name="level_standardexpanded" id="level_standardexpanded43088" value="43088" onclick="evalMatchingGift(''); updateDonorCoverAmount('');" /> </div> <label for="level_standardexpanded43088" onclick=""> <div class="donation-level-label-container"> $50 </div> </label> </div> <input type="hidden" name="level_standardexpandedsubmit" id="level_standard_43088expandedsubmit" value="true" /> </div> </div> <div class="donation-level-container"> <div class="form-content"> <div class="donation-level-input-container form-input"> <div class="donation-level-label-input-container"> <input type="radio" name="level_standardexpanded" id="level_standardexpanded43089" value="43089" onclick="evalMatchingGift(''); updateDonorCoverAmount('');" /> </div> <label for="level_standardexpanded43089" onclick=""> <div class="donation-level-label-container"> $100 </div> </label> </div> <input type="hidden" name="level_standardexpandedsubmit" id="level_standard_43089expandedsubmit" value="true" /> </div> </div> <div class="donation-level-container"> <div class="form-content"> <div class="donation-level-input-container form-input"> <div class="donation-level-label-input-container"> <input type="radio" name="level_standardexpanded" id="level_standardexpanded43090" value="43090" onclick="evalMatchingGift(document.getElementById('level_standardexpanded43090amount').value); updateDonorCoverAmount(document.getElementById('level_standardexpanded43090amount').value);" /> </div> <label for="level_standardexpanded43090" onclick=""> <div class="donation-level-label-container"> Other </div> </label> <div class="donation-level-user-entered"> <label for="level_standardexpanded43090amount"><span class="aural-only">Enter amount</span></label> <input type="text" name="level_standardexpanded43090amount" id="level_standardexpanded43090amount" value="" size="12" maxlength="10" onfocus="var el = document.getElementById ('level_standardexpanded43090');if (el) el.click(); fire_obs_comp_event('level_standardexpanded43090amount', this, event);evalMatchingGift(value); " onchange="fire_obs_comp_event('level_standardexpanded43090amount', this, event);evalMatchingGift(value);" onkeyup="fire_obs_comp_event('level_standardexpanded43090amount', this, event);evalMatchingGift(value);" onblur="fire_obs_comp_event('level_standardexpanded43090amount', this);updateDonorCoverAmount(value);" /> </div> </div> <input type="hidden" name="level_standardexpandedsubmit" id="level_standard_43090expandedsubmit" value="true" /> </div> </div> </div> </div> <script type="text/javascript"> Y.use("jquery-ui", function(Y) { jQuery(function(){ // subscribe observables jQuery('div.donation-level-element-container').find('input[type="radio"]').each(function() { var syncAction = function(obj) { if (obj.is(':checked')) { obj.closest('div.donation-level-container').addClass('selected'); } else { obj.closest('div.donation-level-container').removeClass('selected'); }; return arguments.callee; }(jQuery(this)); jQuery(this).click(function() { jQuery('div.donation-level-container').removeClass('selected'); syncAction(jQuery(this)); }); }); }); }); </script><noscript> </noscript> </div> <div class="levels-gift-aid"> </div> <input type="hidden" name="level_standardsubmit" id="level_standardsubmit" value="true" /> <script type="text/javascript"> function updateDonorCoverAmount(gift) { gift = parseCurrency(gift) / 100; if (isNaN(gift) || gift === 0) { gift = ''; } var amountHidden = document.getElementById('user_donation_amt'); if(amountHidden !== null) { amountHidden.value = gift; } jQuery('#level_standardname').val(gift); jQuery('#user_donation_amt').val(gift); if (typeof updateAmount !== "undefined") { updateAmount(gift); } }; function evalMatchingGift(gift) { } </script><noscript> </noscript> </div> <div class="donation-level-container-generic-repeat form-input"> <div class="generic-repeat-label-checkbox-container"> <input type="checkbox" name="level_standardauto_repeatname" id="level_standardauto_repeatname" onclick="fire_obs_comp_event('level_standardauto_repeat', this);" onkeypress="fire_obs_comp_event('level_standardauto_repeat', this);" /> <input type="hidden" name="recurring_checkbox_name" id="recurring_checkbox_name" value="level_standardauto_repeatname" /> <label for="level_standardauto_repeatname"> Yes, automatically repeat this gift every month. </label> </div> <input type="hidden" name="level_standardauto_repeatsubmit" id="level_standardauto_repeatsubmit" value="true" /> </div> <script type="text/javascript"> // subscribe listeners to make an ajax call to the server to calculate the total amount Y.use('jquery-noconflict', function() { var fetchAmountFunc = function () { // find all the select, textarea, input, etc... and format them into key=val pairs. var params = jQuery('#level_standard_row :input').serialize(); // parse the path and append the key/value pairs above to the url var url = 'https://secure.phoenixchildrensfoundation.org/site/Donation2?idb=635796782&level_standardajaxfetch=true&df_id=12649&12649.donation=form1&mfc_pref=T&level_standardtotalcalculateBtn=true'; var index = url.indexOf("?"); var path = url.substring(0, index); var args = url.substring(index+1, url.length); args += '&' + params; var recurringGiftTermsContainer = jQuery('#recurring_gift_terms_acceptance_message_container'); if(recurringGiftTermsContainer && recurringGiftTermsContainer.length > 0) { jQuery.ajax(path, { data: args, success: function(data) { jQuery('#recurring_gift_terms_acceptance_message_container').trigger("recurringTermsChange"); } }); } }; jQuery('#level_standard_row :input[type=text]').blur(function() { fetchAmountFunc(); }); jQuery('#level_standard_row input:checkbox, #level_standard_row input:radio').click(function() { fetchAmountFunc(); }); jQuery('#level_standard_row select').change(function() { fetchAmountFunc(); }); // call it on page load fetchAmountFunc(); }); </script><noscript> </noscript> </div> <div class="form-row"> <div class="html-caption-container"> <div class="df-copy"> <h1 class="section-header-container">Give the Gift of Hope</h1> <p>Hope means everything to our patients and their families. It’s what keeps them going, even in the darkest moments. And when a child’s life is in the balance, hope can’t wait.</p> <br> <p>You have the power to bring hope to these children and families. Your generous support makes it possible for Phoenix Children’s to provide the very best pediatric care to all Arizona children—and that’s a gift unlike any other. Thank you for investing in our lifesaving work. </p> </div> </div> </div> <h2 class="section-header-container"> Donor Information </h2> <div id="billing_first_name_row" class="form-row form-text"> <div class="form-content"> <span class="field-required"></span> <label for="billing_first_namename">First Name:</label> <input type="text" name="billing_first_namename" id="billing_first_namename" value="" maxlength="50" /> <input type="hidden" name="billing_first_namesubmit" id="billing_first_namesubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('billing_first_name', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('billing_first_name_row', _display); this.disable_submit_flag (_hidden); } </script><noscript> </noscript> </div> </div> <div id="billing_last_name_row" class="form-row form-text"> <div class="form-content"> <span class="field-required"></span> <label for="billing_last_namename">Last Name:</label> <input type="text" name="billing_last_namename" id="billing_last_namename" value="" maxlength="50" /> <input type="hidden" name="billing_last_namesubmit" id="billing_last_namesubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('billing_last_name', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('billing_last_name_row', _display); this.disable_submit_flag (_hidden); } </script><noscript> </noscript> </div> </div> <div id="donor_email_address_row" class="form-row form-text"> <div class="form-content"> <span class="field-required"></span> <label for="donor_email_addressname">Email Address:</label> <input type="text" name="donor_email_addressname" id="donor_email_addressname" value="" maxlength="255" /> <input type="hidden" name="donor_email_addresssubmit" id="donor_email_addresssubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('donor_email_address', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('donor_email_address_row', _display); this.disable_submit_flag (_hidden); } </script><noscript> </noscript> </div> </div> <div id="donor_phone_row" class="form-row form-text"> <div class="form-content"> <label for="donor_phonename">Mobile Phone (Optional)</label> <input type="text" name="donor_phonename" id="donor_phonename" value="" maxlength="50" /> <input type="hidden" name="donor_phonesubmit" id="donor_phonesubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('donor_phone', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('donor_phone_row', _display); this.disable_submit_flag (_hidden); } </script><noscript> </noscript> </div> </div> <div id="billing_addr_country_row" class="form-row form-selectlist"> <div class="form-content"> <label class="FormLabel" for="billing_addr_country">Country:</label> <select name="billing_addr_country" id="billing_addr_country" size="1" onchange="fire_obs_comp_event('billing_addr_country', this)"> <option ></option> <option selected="selected" value="United States" >United States</option> <option value="Afghanistan" >Afghanistan</option> <option value="Aland Islands" >Aland Islands</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="Bolivarian Republic of Venezuela" >Bolivarian Republic of Venezuela</option> <option value="Bonaire, Sint Eustatios and Saba" >Bonaire, Sint Eustatios 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="Cambodia" >Cambodia</option> <option value="Cameroon" >Cameroon</option> <option value="Canada" >Canada</option> <option value="Cape Verde" >Cape Verde</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 (Keeling) Islands" >Cocos (Keeling) Islands</option> <option value="Colombia" >Colombia</option> <option value="Comoros" >Comoros</option> <option value="Congo" >Congo</option> <option value="Cook Islands" >Cook Islands</option> <option value="Costa Rica" >Costa Rica</option> <option value="Cote D'Ivoire" >Cote D'Ivoire</option> <option value="Croatia" >Croatia</option> <option value="Cuba" >Cuba</option> <option value="Curacao" >Curacao</option> <option value="Cyprus" >Cyprus</option> <option value="Czech Republic" >Czech Republic</option> <option value="Democratic People's Republic of Korea" >Democratic People's Republic of Korea</option> <option value="The Democratic Republic of the Congo" >The Democratic Republic of the Congo</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="Ethiopia" >Ethiopia</option> <option value="Falkland Islands (Malvinas)" >Falkland Islands (Malvinas)</option> <option value="Faroe Islands" >Faroe Islands</option> <option value="Federated States of Micronesia" >Federated States of Micronesia</option> <option value="Fiji" >Fiji</option> <option value="Finland" >Finland</option> <option value="The Former Yugoslav Republic of Macedonia" >The Former Yugoslav Republic of Macedonia</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 (Vatican City State)" >Holy See (Vatican City State)</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="Iraq" >Iraq</option> <option value="Ireland" >Ireland</option> <option value="Islamic Republic of Iran" >Islamic Republic of Iran</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="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="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="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="Palestinian Territory, Occupied" >Palestinian Territory, Occupied</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="Plurinational State of Bolivia" >Plurinational State of Bolivia</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="Republic of Korea" >Republic of Korea</option> <option value="Republic of Moldova" >Republic of Moldova</option> <option value="Reunion" >Reunion</option> <option value="Romania" >Romania</option> <option value="Russian Federation" >Russian Federation</option> <option value="Rwanda" >Rwanda</option> <option value="Saint Barthelemy" >Saint Barthelemy</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 (French)" >Saint Martin (French)</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="S. Georgia & S. Sandwich Isls." >S. Georgia & S. Sandwich Isls.</option> <option value="Sierra Leone" >Sierra Leone</option> <option value="Singapore" >Singapore</option> <option value="Sint Maarten (Dutch)" >Sint Maarten (Dutch)</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 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="Swaziland" >Swaziland</option> <option value="Sweden" >Sweden</option> <option value="Switzerland" >Switzerland</option> <option value="Syrian Arab Republic" >Syrian Arab Republic</option> <option value="Taiwan, Province of China" >Taiwan, Province of China</option> <option value="Tajikistan" >Tajikistan</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="Turkey" >Turkey</option> <option value="Turkmenistan" >Turkmenistan</option> <option value="Turks and Caicos Islands" >Turks and Caicos Islands</option> <option value="Tuvalu" >Tuvalu</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 Republic of Tanzania" >United Republic of Tanzania</option> <option value="Uruguay" >Uruguay</option> <option value="USA Minor Outlying Islands" >USA Minor Outlying Islands</option> <option value="Uzbekistan" >Uzbekistan</option> <option value="Vanuatu" >Vanuatu</option> <option value="Viet Nam" >Viet Nam</option> <option value="Virgin Islands (British)" >Virgin Islands (British)</option> <option value="Virgin Islands (USA)" >Virgin Islands (USA)</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> </select> <script type="text/javascript">  </script> <noscript><br/>Required</noscript> <input type="hidden" name="billing_addr_countrysubmit" id="billing_addr_countrysubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('billing_addr_country', ''); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('billing_addr_country_row', _display); this.disable_submit_flag (_hidden); } function billing_addr_country_listChanged(_evt) { var e = _evt ? _evt : event; // IE vs. Mozilla event model if (e) { var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model fire_obs_comp_event('billing_addr_country', src); } } var el = document.getElementById('billing_addr_country'); if (el) { Utils.addEvent (el, 'change', billing_addr_country_listChanged); } </script><noscript> </noscript> </div> </div> <div id="billing_addr_street1_row" class="form-row form-text"> <div class="form-content"> <span class="field-required"></span> <label for="billing_addr_street1name">Street 1:</label> <input type="text" name="billing_addr_street1name" id="billing_addr_street1name" value="" maxlength="50" /> <input type="hidden" name="billing_addr_street1submit" id="billing_addr_street1submit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('billing_addr_street1', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('billing_addr_street1_row', _display); this.disable_submit_flag (_hidden); } </script><noscript> </noscript> </div> </div> <div id="billing_addr_street2_row" class="form-row form-text"> <div class="form-content"> <label for="billing_addr_street2name">Street 2:</label> <input type="text" name="billing_addr_street2name" id="billing_addr_street2name" value="" maxlength="50" /> <input type="hidden" name="billing_addr_street2submit" id="billing_addr_street2submit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('billing_addr_street2', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('billing_addr_street2_row', _display); this.disable_submit_flag (_hidden); } </script><noscript> </noscript> </div> </div> <div id="billing_addr_city_row" class="form-row form-text"> <div class="form-content"> <span class="field-required"></span> <label for="billing_addr_cityname">City:</label> <input type="text" name="billing_addr_cityname" id="billing_addr_cityname" value="" maxlength="50" /> <input type="hidden" name="billing_addr_citysubmit" id="billing_addr_citysubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('billing_addr_city', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('billing_addr_city_row', _display); this.disable_submit_flag (_hidden); } </script><noscript> </noscript> </div> </div> <div id="billing_addr_state_row" class="form-row form-selectlist"> <div class="form-content"> <span class="field-required"></span> <label class="FormLabel" for="billing_addr_state">State/Province:</label> <select name="billing_addr_state" id="billing_addr_state" size="1" onchange="fire_obs_comp_event('billing_addr_state', this)"> <option ></option> <option value="AK" >AK - Alaska</option> <option value="AL" >AL - Alabama</option> <option value="AR" >AR - Arkansas</option> <option value="AZ" >AZ - Arizona</option> <option value="CA" >CA - California</option> <option value="CO" >CO - Colorado</option> <option value="CT" >CT - Connecticut</option> <option value="DC" >DC - District of Columbia</option> <option value="DE" >DE - Delaware</option> <option value="FL" >FL - Florida</option> <option value="GA" >GA - Georgia</option> <option value="HI" >HI - Hawaii</option> <option value="IA" >IA - Iowa</option> <option value="ID" >ID - Idaho</option> <option value="IL" >IL - Illinois</option> <option value="IN" >IN - Indiana</option> <option value="KS" >KS - Kansas</option> <option value="KY" >KY - Kentucky</option> <option value="LA" >LA - Louisiana</option> <option value="MA" >MA - Massachusetts</option> <option value="MD" >MD - Maryland</option> <option value="ME" >ME - Maine</option> <option value="MI" >MI - Michigan</option> <option value="MN" >MN - Minnesota</option> <option value="MO" >MO - Missouri</option> <option value="MS" >MS - Mississippi</option> <option value="MT" >MT - Montana</option> <option value="NC" >NC - North Carolina</option> <option value="ND" >ND - North Dakota</option> <option value="NE" >NE - Nebraska</option> <option value="NH" >NH - New Hampshire</option> <option value="NJ" >NJ - New Jersey</option> <option value="NM" >NM - New Mexico</option> <option value="NV" >NV - Nevada</option> <option value="NY" >NY - New York</option> <option value="OH" >OH - Ohio</option> <option value="OK" >OK - Oklahoma</option> <option value="OR" >OR - Oregon</option> <option value="PA" >PA - Pennsylvania</option> <option value="RI" >RI - Rhode Island</option> <option value="SC" >SC - South Carolina</option> <option value="SD" >SD - South Dakota</option> <option value="TN" >TN - Tennessee</option> <option value="TX" >TX - Texas</option> <option value="UT" >UT - Utah</option> <option value="VA" >VA - Virginia</option> <option value="VT" >VT - Vermont</option> <option value="WA" >WA - Washington</option> <option value="WI" >WI - Wisconsin</option> <option value="WV" >WV - West Virginia</option> <option value="WY" >WY - Wyoming</option> <option value="AS" >AS - American Samoa</option> <option value="FM" >FM - Federated States of Micronesia</option> <option value="GU" >GU - Guam</option> <option value="MH" >MH - Marshall Islands</option> <option value="MP" >MP - Northern Mariana Islands</option> <option value="PR" >PR - Puerto Rico</option> <option value="PW" >PW - Palau</option> <option value="VI" >VI - Virgin Islands</option> <option value="AA" >AA - Armed Forces Americas</option> <option value="AE" >AE - Armed Forces</option> <option value="AP" >AP - Armed Forces Pacific</option> <option value="AB" >AB - Alberta</option> <option value="BC" >BC - British Columbia</option> <option value="MB" >MB - Manitoba</option> <option value="NB" >NB - New Brunswick</option> <option value="NL" >NL - Newfoundland and Labrador</option> <option value="NS" >NS - Nova Scotia</option> <option value="NT" >NT - Northwest Territories</option> <option value="NU" >NU - Nunavut</option> <option value="ON" >ON - Ontario</option> <option value="PE" >PE - Prince Edward Island</option> <option value="QC" >QC - Quebec</option> <option value="SK" >SK - Saskatchewan</option> <option value="YT" >YT - Yukon</option> <option value="None" >None</option> </select> <script type="text/javascript">  </script> <noscript><br/>Required</noscript> <input type="hidden" name="billing_addr_statesubmit" id="billing_addr_statesubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('billing_addr_state', ''); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('billing_addr_state_row', _display); this.disable_submit_flag (_hidden); } function billing_addr_state_listChanged(_evt) { var e = _evt ? _evt : event; // IE vs. Mozilla event model if (e) { var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model fire_obs_comp_event('billing_addr_state', src); } } var el = document.getElementById('billing_addr_state'); if (el) { Utils.addEvent (el, 'change', billing_addr_state_listChanged); } </script><noscript> </noscript> </div> </div> <div id="billing_addr_zip_row" class="form-row form-text"> <div class="form-content"> <span class="field-required"></span> <label for="billing_addr_zipname">ZIP/Postal Code:</label> <input type="text" name="billing_addr_zipname" id="billing_addr_zipname" value="" maxlength="50" /> <input type="hidden" name="billing_addr_zipsubmit" id="billing_addr_zipsubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('billing_addr_zip', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('billing_addr_zip_row', _display); this.disable_submit_flag (_hidden); } </script><noscript> </noscript> </div> </div> <div class="form-row form-checkbox" id="donor_email_opt_in_Row"> <div class="form-content"> <span class="check-box-form-label-text"></span> <input type="hidden" name="donor_email_opt_inname" id="donor_email_opt_inname" value="implicit" /> <span class="auto-opt-in-warning-message">If you donate and have not already registered, you will receive periodic updates and communications from Phoenix Children's Foundation.</span> <script type="text/javascript"> var comp = new ObservableComponent ('donor_email_opt_in', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('donor_email_opt_in_Row', _display); this.disable_submit_flag (_hidden); } comp.set = function (_value) { if (document.getElementById('donor_email_opt_inname')) { document.getElementById('donor_email_opt_inname').checked = _value; this.fireEvent(); } } comp.get = function() { if (document.getElementById('donor_email_opt_inname')) return document.getElementById('donor_email_opt_inname').checked; } comp.clear = function() { this.set(false); } </script><noscript> </noscript> <input type="hidden" name="donor_email_opt_insubmit" id="donor_email_opt_insubmit" value="true" /> </div> </div> <div class="custom-field-container form-row "> <div class="form-content"> <div class="form-input-label-block"> <label for="sms_opt_dropdown">SMS Opt-In</label> </div> <fieldset> <input type="checkbox" name="sms_opt_radio" id="sms_opt_radio" value="true" /> <label class="custom-element-checkbox-label" for="sms_opt_radio">True</label> </fieldset> <input type="hidden" name="sms_optsubmit" id="sms_optsubmit" value="true" /> </div> </div> <h2 class="section-header-container"> Payment Information </h2> <div class="payment-type-element-container"> <div class="payment-type-selection-container payment-field-container"> <h3>Payment Method:</h3> <div id="responsive_payment_typepay_typeradio_row" class="form-row"> <div class="form-content"> <div class="payment-type-selections" id="responsive_payment_typepay_typeradio_payment_types"> <span class="internal-payment"><span class="payment-type-option selected"><input type="radio" name="responsive_payment_typepay_typeradio" id="responsive_payment_typepay_typeradiocredit" value="credit" checked="checked" onclick="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" onkeypress="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" /><label for="responsive_payment_typepay_typeradiocredit"><a href="javascript:void(0);" class="payment-type-label">Credit Card</a></label><script type="text/javascript"> var comp = new ObservableRadioComponent ('responsive_payment_typepay_typeradio', 'name'); </script><noscript> </noscript></span><span class="payment-type-option"><input type="radio" name="responsive_payment_typepay_typeradio" id="responsive_payment_typepay_typeradioach" value="ach" onclick="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" onkeypress="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" /><label for="responsive_payment_typepay_typeradioach"><a href="javascript:void(0);" class="payment-type-label">Checking Account</a></label><script type="text/javascript"> var comp = new ObservableRadioComponent ('responsive_payment_typepay_typeradio', 'name'); </script><noscript> </noscript></span></span> <span class="external-payment"><span class="payment-type-option"><input type="radio" name="responsive_payment_typepay_typeradio" id="responsive_payment_typepay_typeradiopaypal" value="paypal" onclick="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" onkeypress="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" /><label for="responsive_payment_typepay_typeradiopaypal"><a href="javascript:void(0);" class="payment-type-label"><img src="../images/payment/paypal-logo.png" alt="Pay with Paypal" /></a></label><script type="text/javascript"> var comp = new ObservableRadioComponent ('responsive_payment_typepay_typeradio', 'name'); </script><noscript> </noscript></span></span> </div> <input type="hidden" name="responsive_payment_typepay_typeradiosubmit" id="responsive_payment_typepay_typeradiosubmit" value="true" /> <script type="text/javascript"> Y.use("jquery-ui", function(Y) { jQuery(function() { // subscribe observable for payment type options jQuery('.payment-type-option').each(function() { var syncAction = function(obj) { if (obj.hasClass('selected')) { var radioGroupName = obj.find('input').attr('name'); obj.find('input').prop('checked', true); fire_obs_comp_event(radioGroupName, obj.find('input').get()); } return arguments.callee; }(jQuery(this)); jQuery(this).click(function() { jQuery('.payment-type-option').removeClass('selected'); jQuery(this).addClass('selected'); syncAction(jQuery(this)); var selectedValue = jQuery(this).find('input').val(); if (selectedValue == 'paypal' || selectedValue == 'amazon') { // open up a boxinator dialog jQuery(document).trigger('redirect-external'); jQuery('#btn_next').click(); } }); }); }); }); var comp = new ObservableRadioComponent ('responsive_payment_typepay_typeradio', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('responsive_payment_typepay_typeradio_row', _display); this.disable_submit_flag (_hidden); } </script><noscript> </noscript> </div> </div> </div> <div id="payment_cc_container" class="payment-field-container"> <h3>Credit Card Information:</h3> <div id="responsive_payment_typecc_type_row" class="form-row form-radio-array"> <div class="form-content"> <fieldset> <legend>Credit Card Type:</legend> <ul class="radio-array-list"> <li class="tender-row "> <img src="../images/diners_sm.gif" alt="Diners Club" name="responsive_payment_typecc_type_Diners_Club" id="responsive_payment_typecc_type_Diners_Club" /> </li><li class="tender-row "> <img src="../images/discovercard_sm.gif" alt="Discover" name="responsive_payment_typecc_type_Discover" id="responsive_payment_typecc_type_Discover" /> </li><li class="tender-row "> <img src="../images/amex_small.gif" alt="American Express" name="responsive_payment_typecc_type_American_Express" id="responsive_payment_typecc_type_American_Express" /> </li><li class="tender-row "> <img src="../images/mastercd_small.gif" alt="MasterCard" name="responsive_payment_typecc_type_MasterCard" id="responsive_payment_typecc_type_MasterCard" /> </li><li class="tender-row "> <img src="../images/visa_small.gif" alt="Visa" name="responsive_payment_typecc_type_Visa" id="responsive_payment_typecc_type_Visa" /> </li> </ul> </fieldset> <input type="hidden" name="responsive_payment_typecc_typesubmit" id="responsive_payment_typecc_typesubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableRadioComponent ('responsive_payment_typecc_type', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('responsive_payment_typecc_type_row', _display); this.disable_submit_flag (_hidden); } </script><noscript> </noscript> <input type="hidden" name="recurring_options_name_install_plan" id="recurring_options_name_install_plan" value="responsive_payment_typecc_type" /> </div> </div> <div id="responsive_payment_typecc_number_row" class="form-row form-text"> <div class="form-content"> <span class="field-required"></span> <label for="responsive_payment_typecc_numbername">Credit Card Number:</label> <input type="text" name="responsive_payment_typecc_numbername" id="responsive_payment_typecc_numbername" value="" maxlength="22" autocomplete="off"/> <input type="hidden" name="responsive_payment_typecc_numbersubmit" id="responsive_payment_typecc_numbersubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('responsive_payment_typecc_number', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('responsive_payment_typecc_number_row', _display); this.disable_submit_flag (_hidden); } observe_component ('null', new ComponentDisplayer ('responsive_payment_typecc_number')); </script><noscript> </noscript> </div> </div> <div id="responsive_payment_typecc_exp_date_row" class="form-row form-date"> <div class="form-content"> <span class="field-required"></span> <label for="responsive_payment_typecc_exp_date_MONTH"> <span class="label-text">Expiration Date:</span><span class="aural-only">Select month of credit card</span> </label> <label for="responsive_payment_typecc_exp_date_YEAR" ><span class="aural-only">Select Expiration Year</span></label> <div class="date-input-container"> <fieldset class="cardExpGroup"> <select name="responsive_payment_typecc_exp_date_MONTH" id="responsive_payment_typecc_exp_date_MONTH" onChange="fire_obs_comp_event('responsive_payment_typecc_exp_date_MONTH', this)"> <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" selected="selected">11</option> <option value="12" >12</option> </select> <select name="responsive_payment_typecc_exp_date_YEAR" id="responsive_payment_typecc_exp_date_YEAR" onChange="fire_obs_comp_event('responsive_payment_typecc_exp_date_YEAR', this)"> <option value="2024" selected="selected">2024</option> <option value="2025" >2025</option> <option value="2026" >2026</option> <option value="2027" >2027</option> <option value="2028" >2028</option> <option value="2029" >2029</option> <option value="2030" >2030</option> <option value="2031" >2031</option> <option value="2032" >2032</option> <option value="2033" >2033</option> <option value="2034" >2034</option> </select> </fieldset> <input type="hidden" name="responsive_payment_typecc_exp_date_DAY" id="responsive_payment_typecc_exp_date_DAY" value="1" /> <script type="text/javascript">  </script><noscript> </noscript> </div> <input type="hidden" name="responsive_payment_typecc_exp_datesubmit" id="responsive_payment_typecc_exp_datesubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('responsive_payment_typecc_exp_date', 'input'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('responsive_payment_typecc_exp_date_row', _display); disable_submit_flag ('responsive_payment_typecc_exp_datesubmit', _hidden); } comp.disable = function(_disabled) { disable_element ('responsive_payment_typecc_exp_date_MONTH', _disabled); disable_element ('responsive_payment_typecc_exp_date_DAY', _disabled); disable_element ('responsive_payment_typecc_exp_date_YEAR', _disabled); disable_element ('responsive_payment_typecc_exp_date_HOUR12',_disabled); disable_element ('responsive_payment_typecc_exp_date_HOUR24',_disabled); //For UK, 24 hour clock used disable_element ('responsive_payment_typecc_exp_date_MINUTE',_disabled); disable_element ('responsive_payment_typecc_exp_date_AMPM', _disabled); } </script><noscript> </noscript> </div> </div> <div id="responsive_payment_typecc_cvv_row" class="form-row form-text cvv-input"> <div class="form-content"> <span class="field-required"></span> <label for="responsive_payment_typecc_cvvname"> <span class="FormLabelText">CVV Number:</span> </label> <a href="http://help.convio.net/site/PageServer?s_site=pch&pagename=user_donation_cvv" class="HelpLink" title="What is this? Opens new window.">What is this?</a> <input type="text" name="responsive_payment_typecc_cvvname" id="responsive_payment_typecc_cvvname" value="" maxlength="4" autocomplete="off" /> <input type="hidden" name="responsive_payment_typecc_cvvsubmit" id="responsive_payment_typecc_cvvsubmit" value="true" /> <script type="text/javascript"> //chrome is mapping cvv as card name if (/CriOS/.test(navigator.userAgent) || (/Chrome/.test(navigator.userAgent) && /Google Inc/.test(navigator.vendor))){ document.getElementById('responsive_payment_typecc_cvvname').autocomplete='cc-csc'; } var comp = new ObservableComponent ('responsive_payment_typecc_cvv', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('responsive_payment_typecc_cvv_row', _display); this.disable_submit_flag (_hidden); } </script><noscript> </noscript> </div> </div> </div> <div id="payment_bank_container" class="payment-field-container"> <h3>Checking Account Information:</h3> <div id="responsive_payment_typerouting_number_row" class="form-row form-text"> <div class="form-content"> <span class="field-required"></span> <label for="responsive_payment_typerouting_numbername">Bank Routing Number:</label> <a href="http://help.convio.net/site/PageServer?s_site=pch&pagename=User_Donation_ACH" class="HelpLink" title="What is this? Opens new window.">What is this?</a> <input type="text" name="responsive_payment_typerouting_numbername" id="responsive_payment_typerouting_numbername" value="" size="20" maxlength="20" onchange="fire_obs_comp_event('responsive_payment_typerouting_number', this);" autocomplete="off" /> <input type="hidden" name="responsive_payment_typerouting_numbersubmit" id="responsive_payment_typerouting_numbersubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('responsive_payment_typerouting_number', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('responsive_payment_typerouting_number_row', _display); this.disable_submit_flag (_hidden); } </script><noscript> </noscript> </div> </div> <div id="responsive_payment_typebank_account_row" class="form-row form-text"> <div class="form-content"> <span class="field-required"></span> <label for="responsive_payment_typebank_accountname">Bank Account Number:</label> <input type="text" name="responsive_payment_typebank_accountname" id="responsive_payment_typebank_accountname" value="" maxlength="20" autocomplete="off"/> <input type="hidden" name="responsive_payment_typebank_accountsubmit" id="responsive_payment_typebank_accountsubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('responsive_payment_typebank_account', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('responsive_payment_typebank_account_row', _display); this.disable_submit_flag (_hidden); } observe_component ('null', new ComponentDisplayer ('responsive_payment_typebank_account')); </script><noscript> </noscript> </div> </div> <div id="responsive_payment_typeverify_bank_account_row" class="form-row form-text"> <div class="form-content"> <span class="field-required"></span> <label for="responsive_payment_typeverify_bank_accountname">Verify Bank Account Number:</label> <input type="text" name="responsive_payment_typeverify_bank_accountname" id="responsive_payment_typeverify_bank_accountname" value="" maxlength="20" autocomplete="off"/> <input type="hidden" name="responsive_payment_typeverify_bank_accountsubmit" id="responsive_payment_typeverify_bank_accountsubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('responsive_payment_typeverify_bank_account', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('responsive_payment_typeverify_bank_account_row', _display); this.disable_submit_flag (_hidden); } observe_component ('null', new ComponentDisplayer ('responsive_payment_typeverify_bank_account')); </script><noscript> </noscript> </div> </div><div id="responsive_payment_type.account_type_row" class="form-row form-radio-array"> <div class="form-content"> <fieldset> <legend><span class="field-required"></span> Account Type:</legend> <ul class="radio-array-list"> <li> <input type="radio" name="responsive_payment_type.account_type" id="responsive_payment_type.account_type_responsive_payment_typeaccount_type_checking" value="CHECKING" onclick="fire_obs_comp_event('responsive_payment_type.account_type', this);" /> <span class="radio-label"> <label for="responsive_payment_type.account_type_responsive_payment_typeaccount_type_checking" >Checking</label> </span> </li><li> <input type="radio" name="responsive_payment_type.account_type" id="responsive_payment_type.account_type_responsive_payment_typeaccount_type_savings" value="SAVINGS" onclick="fire_obs_comp_event('responsive_payment_type.account_type', this);" /> <span class="radio-label"> <label for="responsive_payment_type.account_type_responsive_payment_typeaccount_type_savings" >Savings</label> </span> </li> </ul> </fieldset> <input type="hidden" name="responsive_payment_type.account_typesubmit" id="responsive_payment_type.account_typesubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableRadioComponent ('responsive_payment_type.account_type', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('responsive_payment_type.account_type_row', _display); this.disable_submit_flag (_hidden); } </script><noscript> </noscript> <input type="hidden" name="recurring_options_name_install_plan" id="recurring_options_name_install_plan" value="responsive_payment_type.account_type" /> </div> </div> <div id="responsive_payment_typeach_confirm_row" class="form-row form-checkbox"> <div class="form-content"> <span class="field-required"></span> <input type="checkbox" name="responsive_payment_typeach_confirmname" id="responsive_payment_typeach_confirmname" onclick="fire_obs_comp_event('responsive_payment_typeach_confirm', this);" /> <label for="responsive_payment_typeach_confirmname">By checking this option, I agree to use my bank account as a payment method and authorize this organization to debit my bank account to fulfill my donation commitment.</label> <input type="hidden" name="responsive_payment_typeach_confirmsubmit" id="responsive_payment_typeach_confirmsubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('responsive_payment_typeach_confirm', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('responsive_payment_typeach_confirm_row', _display); this.disable_submit_flag (_hidden); } comp.set = function (_value) { if (document.getElementById('responsive_payment_typeach_confirmname')) { document.getElementById('responsive_payment_typeach_confirmname').checked = _value; this.fireEvent(); } } comp.get = function() { if (document.getElementById('responsive_payment_typeach_confirmname')) { return document.getElementById('responsive_payment_typeach_confirmname').checked; } } comp.clear = function() { this.set(false); } observe_component ('null', new ComponentEnabler ('responsive_payment_typeach_confirm')); </script><noscript> </noscript> </div> </div> </div> <div id="payment_check_container" class="payment-field-container"> <h3>Check Information</h3> </div> <script> document.addEventListener("DOMContentLoaded", function () { addHiddenInputIfNotExist("cc_available", "cc_available", "null"); addHiddenInputIfNotExist("debit_available", "debit_available", "null"); addHiddenInputIfNotExist("paypal_available", "paypal_available", "null"); addHiddenInputIfNotExist("wallets_available", "wallets_available", "null"); addHiddenInputIfNotExist("secure_url", "secure_url", "https://secure.phoenixchildrensfoundation.org/site/"); addHiddenInputIfNotExist("is_admin_app", "is_admin_app", "F"); addHiddenInputIfNotExist("environment_id", "environment_id", ""); addHiddenInputIfNotExist("merchant_account_configuration_id", "merchant_account_configuration_id", ""); addHiddenInputIfNotExist("pco_javascript_location", "pco_javascript_location", ""); addHiddenInputIfNotExist("primary_color", "primary_color", "null"); addHiddenInputIfNotExist("application_name", "application_name", "TeamRaiser"); addHiddenInputIfNotExist("pco_language_locale", "pco_language_locale", "en_US"); addHiddenInputIfNotExist("pco_environment_zone", "pco_environment_zone", "p-usa01"); }); </script> <input type="hidden" name="responsive_payment_typesubmit" id="responsive_payment_typesubmit" value="true" /> <script type="text/javascript"> function PaymentObserver() { this.observe = function(_event) { var sVal = _event.component.get(); switch (sVal) { case 'check': hide_element('payment_cc_container'); hide_element('payment_bank_container'); show_element('payment_check_container'); break; case 'credit': hide_element('payment_bank_container'); hide_element('payment_check_container'); show_element('payment_cc_container'); break; case 'ach': hide_element('payment_cc_container'); hide_element('payment_check_container'); show_element('payment_bank_container'); break; case 'paypal': case 'amazon': case 'mobilepay': default: // hide all hide_element('payment_bank_container'); hide_element('payment_cc_container'); hide_element('payment_check_container'); break; } } } // Set the observer to show/hide the relevant fields observe_component ('responsive_payment_typepay_typeradio', new PaymentObserver()); </script><noscript> </noscript> </div> <div id="donor_remember_me_row" class="form-row form-checkbox"> <div class="form-content"> <input type="checkbox" name="donor_remember_mename" id="donor_remember_mename" checked="checked" onclick="fire_obs_comp_event('donor_remember_me', this);" /> <label for="donor_remember_mename">Save me time in the future and remember me on this computer.</label> <input type="hidden" name="donor_remember_mesubmit" id="donor_remember_mesubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('donor_remember_me', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('donor_remember_me_row', _display); this.disable_submit_flag (_hidden); } comp.set = function (_value) { if (document.getElementById('donor_remember_mename')) { document.getElementById('donor_remember_mename').checked = _value; this.fireEvent(); } } comp.get = function() { if (document.getElementById('donor_remember_mename')) { return document.getElementById('donor_remember_mename').checked; } } comp.clear = function() { this.set(false); } </script><noscript> </noscript> </div> </div> <div class="custom-field-container form-row "> <div class="form-content"> <div class="form-input-label-block"> <label for="null_input">I want my gift to support</label> </div> <fieldset> <div class="radio-button-container"> <input type="radio" name="null_radio" id="null_radio_cv_list" value="_cv_list" /> <select name="null_dropdown" id="null_dropdown" size="1" > <option value="The Hope Fund (Area of Immediate Need) - 1088" >The Hope Fund (Area of Immediate Need)</option> <option value="Patient and Family Assistance Fund - 1022" >Patient and Family Assistance Fund</option> <option value="Center for Cancer and Blood Disorders" >Center for Cancer and Blood Disorders</option> <option value="Center for Heart Care" >Center for Heart Care</option> <option value="Barrow Neurological Institute at Phoenix Children's" >Barrow Neurological Institute at Phoenix Children's</option> <option value="Newborn Intensive Care Unit" >Newborn Intensive Care Unit</option> <option value="Other (please specify below in Notes)" >Other (please specify below in Notes)</option> </select> <script type="text/javascript">  </script> <noscript><br/>Required</noscript> <label class="aural-only" for="null_radio_cv_list">This radio option selects the field value from the following selection list.</label> </div> <div class="radio-button-container"> <input type="radio" name="null_radio" id="null_radio_cv_txt" value="_cv_txt" /> <label class="aural-only" for="null_radio_cv_txt">This radio option selects the field value from the following text input field.</label> <input type="text" name="null_input" id="null_input" value="" maxlength="255" /> </div> </fieldset> <input type="hidden" name="nullsubmit" id="nullsubmit" value="true" /> </div> </div> <div class="custom-field-container form-row "> <div class="form-content"> <div class="form-input-label-block"> <label for="null_input">Notes about your gift (optional):</label> </div> <input type="text" name="null_input" id="null_input" value="" maxlength="255" /> <input type="hidden" name="nullsubmit" id="nullsubmit" value="true" /> </div> </div> <div id="tribute_show_honor_fields_row" class="form-row form-checkbox"> <div class="form-content"> <input type="checkbox" name="tribute_show_honor_fieldsname" id="tribute_show_honor_fieldsname" onclick="fire_obs_comp_event('tribute_show_honor_fields', this);" /> <label for="tribute_show_honor_fieldsname">Yes, this is an honor or memorial gift</label> <input type="hidden" name="tribute_show_honor_fieldssubmit" id="tribute_show_honor_fieldssubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('tribute_show_honor_fields', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('tribute_show_honor_fields_row', _display); this.disable_submit_flag (_hidden); } comp.set = function (_value) { if (document.getElementById('tribute_show_honor_fieldsname')) { document.getElementById('tribute_show_honor_fieldsname').checked = _value; this.fireEvent(); } } comp.get = function() { if (document.getElementById('tribute_show_honor_fieldsname')) { return document.getElementById('tribute_show_honor_fieldsname').checked; } } comp.clear = function() { this.set(false); } </script><noscript> </noscript> </div> </div> <div id="tribute_type_row" class="form-row form-selectlist"> <div class="form-content"> <span class="field-required"></span> <label class="FormLabel" for="tribute_type">Honor Gift Type:</label> <select name="tribute_type" id="tribute_type" size="1" > <option ></option> <option value="tribute_type_value1" >In Memory of</option> <option value="tribute_type_value2" >In Honor of</option> </select> <script type="text/javascript">  </script> <noscript><br/>Required</noscript> <input type="hidden" name="tribute_typesubmit" id="tribute_typesubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('tribute_type', ''); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('tribute_type_row', _display); this.disable_submit_flag (_hidden); } observe_component ('tribute_show_honor_fields.true', new ComponentDisplayer ('tribute_type')); function tribute_type_listChanged(_evt) { var e = _evt ? _evt : event; // IE vs. Mozilla event model if (e) { var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model fire_obs_comp_event('tribute_type', src); } } var el = document.getElementById('tribute_type'); if (el) { Utils.addEvent (el, 'change', tribute_type_listChanged); } </script><noscript> </noscript> </div> </div> <div id="tribute_honoree_name_row" class="form-row form-text"> <div class="form-content"> <span class="field-required"></span> <label for="tribute_honoree_namename">Honoree Name:</label> <input type="text" name="tribute_honoree_namename" id="tribute_honoree_namename" value="" maxlength="50" /> <input type="hidden" name="tribute_honoree_namesubmit" id="tribute_honoree_namesubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('tribute_honoree_name', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('tribute_honoree_name_row', _display); this.disable_submit_flag (_hidden); } observe_component ('tribute_show_honor_fields.true', new ComponentDisplayer ('tribute_honoree_name')); </script><noscript> </noscript> </div> </div> <div id="tribute_notify_recip_name_row" class="form-row form-text"> <div class="form-content"> <span class="field-required"></span> <label for="tribute_notify_recip_namename">Notification Recipient Name:</label> <input type="text" name="tribute_notify_recip_namename" id="tribute_notify_recip_namename" value="" maxlength="70" /> <input type="hidden" name="tribute_notify_recip_namesubmit" id="tribute_notify_recip_namesubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('tribute_notify_recip_name', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('tribute_notify_recip_name_row', _display); this.disable_submit_flag (_hidden); } observe_component ('tribute_show_honor_fields.true', new ComponentDisplayer ('tribute_notify_recip_name')); </script><noscript> </noscript> </div> </div> <div id="tribute_notify_recip_street1_row" class="form-row form-text"> <div class="form-content"> <span class="field-required"></span> <label for="tribute_notify_recip_street1name">Notification Recipient Street 1:</label> <input type="text" name="tribute_notify_recip_street1name" id="tribute_notify_recip_street1name" value="" maxlength="50" /> <input type="hidden" name="tribute_notify_recip_street1submit" id="tribute_notify_recip_street1submit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('tribute_notify_recip_street1', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('tribute_notify_recip_street1_row', _display); this.disable_submit_flag (_hidden); } observe_component ('tribute_show_honor_fields.true', new ComponentDisplayer ('tribute_notify_recip_street1')); </script><noscript> </noscript> </div> </div> <div id="tribute_notify_recip_street2_row" class="form-row form-text"> <div class="form-content"> <label for="tribute_notify_recip_street2name">Notification Recipient Street 2:</label> <input type="text" name="tribute_notify_recip_street2name" id="tribute_notify_recip_street2name" value="" maxlength="50" /> <input type="hidden" name="tribute_notify_recip_street2submit" id="tribute_notify_recip_street2submit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('tribute_notify_recip_street2', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('tribute_notify_recip_street2_row', _display); this.disable_submit_flag (_hidden); } observe_component ('tribute_show_honor_fields.true', new ComponentDisplayer ('tribute_notify_recip_street2')); </script><noscript> </noscript> </div> </div> <div id="tribute_notify_recip_city_row" class="form-row form-text"> <div class="form-content"> <span class="field-required"></span> <label for="tribute_notify_recip_cityname">Notification Recipient City:</label> <input type="text" name="tribute_notify_recip_cityname" id="tribute_notify_recip_cityname" value="" maxlength="50" /> <input type="hidden" name="tribute_notify_recip_citysubmit" id="tribute_notify_recip_citysubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('tribute_notify_recip_city', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('tribute_notify_recip_city_row', _display); this.disable_submit_flag (_hidden); } observe_component ('tribute_show_honor_fields.true', new ComponentDisplayer ('tribute_notify_recip_city')); </script><noscript> </noscript> </div> </div> <div id="tribute_notify_recip_state_row" class="form-row form-selectlist"> <div class="form-content"> <span class="field-required"></span> <label class="FormLabel" for="tribute_notify_recip_state">Notification Recipient State/Province:</label> <select name="tribute_notify_recip_state" id="tribute_notify_recip_state" size="1" onchange="fire_obs_comp_event('tribute_notify_recip_state', this)"> <option ></option> <option value="AK" >AK - Alaska</option> <option value="AL" >AL - Alabama</option> <option value="AR" >AR - Arkansas</option> <option value="AZ" >AZ - Arizona</option> <option value="CA" >CA - California</option> <option value="CO" >CO - Colorado</option> <option value="CT" >CT - Connecticut</option> <option value="DC" >DC - District of Columbia</option> <option value="DE" >DE - Delaware</option> <option value="FL" >FL - Florida</option> <option value="GA" >GA - Georgia</option> <option value="HI" >HI - Hawaii</option> <option value="IA" >IA - Iowa</option> <option value="ID" >ID - Idaho</option> <option value="IL" >IL - Illinois</option> <option value="IN" >IN - Indiana</option> <option value="KS" >KS - Kansas</option> <option value="KY" >KY - Kentucky</option> <option value="LA" >LA - Louisiana</option> <option value="MA" >MA - Massachusetts</option> <option value="MD" >MD - Maryland</option> <option value="ME" >ME - Maine</option> <option value="MI" >MI - Michigan</option> <option value="MN" >MN - Minnesota</option> <option value="MO" >MO - Missouri</option> <option value="MS" >MS - Mississippi</option> <option value="MT" >MT - Montana</option> <option value="NC" >NC - North Carolina</option> <option value="ND" >ND - North Dakota</option> <option value="NE" >NE - Nebraska</option> <option value="NH" >NH - New Hampshire</option> <option value="NJ" >NJ - New Jersey</option> <option value="NM" >NM - New Mexico</option> <option value="NV" >NV - Nevada</option> <option value="NY" >NY - New York</option> <option value="OH" >OH - Ohio</option> <option value="OK" >OK - Oklahoma</option> <option value="OR" >OR - Oregon</option> <option value="PA" >PA - Pennsylvania</option> <option value="RI" >RI - Rhode Island</option> <option value="SC" >SC - South Carolina</option> <option value="SD" >SD - South Dakota</option> <option value="TN" >TN - Tennessee</option> <option value="TX" >TX - Texas</option> <option value="UT" >UT - Utah</option> <option value="VA" >VA - Virginia</option> <option value="VT" >VT - Vermont</option> <option value="WA" >WA - Washington</option> <option value="WI" >WI - Wisconsin</option> <option value="WV" >WV - West Virginia</option> <option value="WY" >WY - Wyoming</option> <option value="AS" >AS - American Samoa</option> <option value="FM" >FM - Federated States of Micronesia</option> <option value="GU" >GU - Guam</option> <option value="MH" >MH - Marshall Islands</option> <option value="MP" >MP - Northern Mariana Islands</option> <option value="PR" >PR - Puerto Rico</option> <option value="PW" >PW - Palau</option> <option value="VI" >VI - Virgin Islands</option> <option value="AA" >AA - Armed Forces Americas</option> <option value="AE" >AE - Armed Forces</option> <option value="AP" >AP - Armed Forces Pacific</option> <option value="AB" >AB - Alberta</option> <option value="BC" >BC - British Columbia</option> <option value="MB" >MB - Manitoba</option> <option value="NB" >NB - New Brunswick</option> <option value="NL" >NL - Newfoundland and Labrador</option> <option value="NS" >NS - Nova Scotia</option> <option value="NT" >NT - Northwest Territories</option> <option value="NU" >NU - Nunavut</option> <option value="ON" >ON - Ontario</option> <option value="PE" >PE - Prince Edward Island</option> <option value="QC" >QC - Quebec</option> <option value="SK" >SK - Saskatchewan</option> <option value="YT" >YT - Yukon</option> <option value="None" >None</option> </select> <script type="text/javascript">  </script> <noscript><br/>Required</noscript> <input type="hidden" name="tribute_notify_recip_statesubmit" id="tribute_notify_recip_statesubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('tribute_notify_recip_state', ''); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('tribute_notify_recip_state_row', _display); this.disable_submit_flag (_hidden); } observe_component ('tribute_show_honor_fields.true', new ComponentDisplayer ('tribute_notify_recip_state')); function tribute_notify_recip_state_listChanged(_evt) { var e = _evt ? _evt : event; // IE vs. Mozilla event model if (e) { var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model fire_obs_comp_event('tribute_notify_recip_state', src); } } var el = document.getElementById('tribute_notify_recip_state'); if (el) { Utils.addEvent (el, 'change', tribute_notify_recip_state_listChanged); } </script><noscript> </noscript> </div> </div> <div id="tribute_notify_recip_zip_row" class="form-row form-text"> <div class="form-content"> <span class="field-required"></span> <label for="tribute_notify_recip_zipname">Notification Recipient ZIP/Postal Code:</label> <input type="text" name="tribute_notify_recip_zipname" id="tribute_notify_recip_zipname" value="" maxlength="50" /> <input type="hidden" name="tribute_notify_recip_zipsubmit" id="tribute_notify_recip_zipsubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('tribute_notify_recip_zip', 'name'); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('tribute_notify_recip_zip_row', _display); this.disable_submit_flag (_hidden); } observe_component ('tribute_show_honor_fields.true', new ComponentDisplayer ('tribute_notify_recip_zip')); </script><noscript> </noscript> </div> </div> <div id="tribute_notify_recip_country_row" class="form-row form-selectlist"> <div class="form-content"> <span class="field-required"></span> <label class="FormLabel" for="tribute_notify_recip_country">Notification Recipient Country:</label> <select name="tribute_notify_recip_country" id="tribute_notify_recip_country" size="1" onchange="fire_obs_comp_event('tribute_notify_recip_country', this)"> <option ></option> <option selected="selected" value="United States" >United States</option> <option value="Afghanistan" >Afghanistan</option> <option value="Aland Islands" >Aland Islands</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="Bolivarian Republic of Venezuela" >Bolivarian Republic of Venezuela</option> <option value="Bonaire, Sint Eustatios and Saba" >Bonaire, Sint Eustatios 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="Cambodia" >Cambodia</option> <option value="Cameroon" >Cameroon</option> <option value="Canada" >Canada</option> <option value="Cape Verde" >Cape Verde</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 (Keeling) Islands" >Cocos (Keeling) Islands</option> <option value="Colombia" >Colombia</option> <option value="Comoros" >Comoros</option> <option value="Congo" >Congo</option> <option value="Cook Islands" >Cook Islands</option> <option value="Costa Rica" >Costa Rica</option> <option value="Cote D'Ivoire" >Cote D'Ivoire</option> <option value="Croatia" >Croatia</option> <option value="Cuba" >Cuba</option> <option value="Curacao" >Curacao</option> <option value="Cyprus" >Cyprus</option> <option value="Czech Republic" >Czech Republic</option> <option value="Democratic People's Republic of Korea" >Democratic People's Republic of Korea</option> <option value="The Democratic Republic of the Congo" >The Democratic Republic of the Congo</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="Ethiopia" >Ethiopia</option> <option value="Falkland Islands (Malvinas)" >Falkland Islands (Malvinas)</option> <option value="Faroe Islands" >Faroe Islands</option> <option value="Federated States of Micronesia" >Federated States of Micronesia</option> <option value="Fiji" >Fiji</option> <option value="Finland" >Finland</option> <option value="The Former Yugoslav Republic of Macedonia" >The Former Yugoslav Republic of Macedonia</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 (Vatican City State)" >Holy See (Vatican City State)</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="Iraq" >Iraq</option> <option value="Ireland" >Ireland</option> <option value="Islamic Republic of Iran" >Islamic Republic of Iran</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="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="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="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="Palestinian Territory, Occupied" >Palestinian Territory, Occupied</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="Plurinational State of Bolivia" >Plurinational State of Bolivia</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="Republic of Korea" >Republic of Korea</option> <option value="Republic of Moldova" >Republic of Moldova</option> <option value="Reunion" >Reunion</option> <option value="Romania" >Romania</option> <option value="Russian Federation" >Russian Federation</option> <option value="Rwanda" >Rwanda</option> <option value="Saint Barthelemy" >Saint Barthelemy</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 (French)" >Saint Martin (French)</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="S. Georgia & S. Sandwich Isls." >S. Georgia & S. Sandwich Isls.</option> <option value="Sierra Leone" >Sierra Leone</option> <option value="Singapore" >Singapore</option> <option value="Sint Maarten (Dutch)" >Sint Maarten (Dutch)</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 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="Swaziland" >Swaziland</option> <option value="Sweden" >Sweden</option> <option value="Switzerland" >Switzerland</option> <option value="Syrian Arab Republic" >Syrian Arab Republic</option> <option value="Taiwan, Province of China" >Taiwan, Province of China</option> <option value="Tajikistan" >Tajikistan</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="Turkey" >Turkey</option> <option value="Turkmenistan" >Turkmenistan</option> <option value="Turks and Caicos Islands" >Turks and Caicos Islands</option> <option value="Tuvalu" >Tuvalu</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 Republic of Tanzania" >United Republic of Tanzania</option> <option value="Uruguay" >Uruguay</option> <option value="USA Minor Outlying Islands" >USA Minor Outlying Islands</option> <option value="Uzbekistan" >Uzbekistan</option> <option value="Vanuatu" >Vanuatu</option> <option value="Viet Nam" >Viet Nam</option> <option value="Virgin Islands (British)" >Virgin Islands (British)</option> <option value="Virgin Islands (USA)" >Virgin Islands (USA)</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> </select> <script type="text/javascript">  </script> <noscript><br/>Required</noscript> <input type="hidden" name="tribute_notify_recip_countrysubmit" id="tribute_notify_recip_countrysubmit" value="true" /> <script type="text/javascript"> var comp = new ObservableComponent ('tribute_notify_recip_country', ''); comp.hide = function(_hidden) { var _display = _hidden ? 'none' : ''; set_display ('tribute_notify_recip_country_row', _display); this.disable_submit_flag (_hidden); } observe_component ('tribute_show_honor_fields.true', new ComponentDisplayer ('tribute_notify_recip_country')); function tribute_notify_recip_country_listChanged(_evt) { var e = _evt ? _evt : event; // IE vs. Mozilla event model if (e) { var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model fire_obs_comp_event('tribute_notify_recip_country', src); } } var el = document.getElementById('tribute_notify_recip_country'); if (el) { Utils.addEvent (el, 'change', tribute_notify_recip_country_listChanged); } </script><noscript> </noscript> </div> </div> <div id="captcha_row" class="form-row form-captcha"> <div class="form-content"> <input type="hidden" name="captcha_text" id="captcha_text" value="" /> <input type="hidden" name="captcha_text_proxy_submit" id="captcha_text_proxy_submit" value="" /> <script src="https://www.google.com/recaptcha/api.js?render=6LcVyLgZAAAAAIaCdeocZ0n27ZV5AVFs-ptKOles"></script> <script type="text/javascript"> Y.use('jquery-noconflict', function() { jQuery(document).ready(function() { var elements; elements = jQuery('#captcha_text').parents('form').find('input[type="submit"], button[type="submit"], input[type="button"], button[type="button"]'); elements.click(function(e) { if (e.target.id === "pstep_finish_validate") { return; } e.preventDefault(); e.stopPropagation(); jQuery('#captcha_text_proxy_submit').val(this.value); jQuery('#captcha_text_proxy_submit').prop('name',this.name); grecaptcha.ready(function() { grecaptcha.execute('6LcVyLgZAAAAAIaCdeocZ0n27ZV5AVFs-ptKOles', {action: 'submit'}).then(function(token) { jQuery('#captcha_text').val(token); if (typeof checkDoubleClick === "function") { if (checkDoubleClick()) { jQuery('#captcha_text').parents('form')[0].submit(); } } else { jQuery('#captcha_text').parents('form')[0].submit(); } }); }); }); }); }); </script> <style type="text/css"> .grecaptcha-badge { visibility: visible !important; } </style> </div> <input type="hidden" name="captchasubmit" id="captchasubmit" value="true" /> </div> <div class="button-container clearfix"> <div class="button-sub-container"> <button class="step-button action-button finish-step" type="submit" id="pstep_finish" name="pstep_finish" value="Make My Gift">Make My Gift</button> </div> </div> <input type="hidden" name="idb" id="idb" value="635796782" /> <input type="hidden" name="df_id" id="df_id" value="12649" /> <input type="hidden" name="mfc_pref" id="mfc_pref" value="T" /> <div class="form-row"> <div class="html-caption-container"> <div id="badge-container"> <div class="new-badge"><img src="../images/content/pagebuilder/Badge-ChildrensHospitals-10Specialties-2021-22.png?t=1641451578012" alt="Best Children's Hospital - U.S. News & World Report - Ranked in 10 Specialties 2021-22" width="100" height="auto" /></div>  <div id="DigiCertClickID_E55LF1Je" class="new-badge"> </div> </div>  <script type="text/javascript">// <![CDATA[ var __dcid = __dcid || []; __dcid.push({ "cid": "DigiCertClickID_E55LF1Je", "tag": "E55LF1Je" }); (function() { var cid = document.createElement("script"); cid.async = true; cid.src = "//seal.digicert.com/seals/cascade/seal.min.js"; var s = document.getElementsByTagName("script"); var ls = s[(s.length - 1)]; ls.parentNode.insertBefore(cid, ls.nextSibling); }()); // ]]></script>  <script> // Updated 2024-09-04 // use supported jQuery for LO Y.use('jquery-noconflict', function() { // console.warn('SMS Opt v0.1.0'); // Wait for the SMS Opt checkbox to appear waitForElement('#sms_opt_radio').then((smsOptInput) => { // Style the parent element to display = flex smsOptInput.parentElement.style.display = 'flex'; // Change the checkbox styles smsOptInput.style.flex = '0 0 30px'; smsOptInput.style.height = '54px'; smsOptInput.style.width = 'unset'; // Change the inner HTML of the label let smsOptLabel = document.querySelector('label[for=sms_opt_radio]'); smsOptLabel.innerHTML = "I agree to receive periodic text messages from Phoenix Children’s Foundation about the impact of my donation and to let me know about upcoming events, promotions and campaigns. You can opt-out at any time."; smsOptLabel.style.paddingTop = '0'; smsOptLabel.style.maxWidth = '100%'; // If the checkbox is not checked, click it if (!smsOptInput.checked) { smsOptInput.click(); } // Scroll to the top of the page window.scrollTo(0, 0); }).catch((error) => { console.error('Error waiting for SMS Opt checkbox:', error); }); // Generic function to watch for an element to appear function waitForElement(selector) { return new Promise((resolve, reject) => { const element = document.querySelector(selector); if (element) { return resolve(element); } const observer = new MutationObserver((mutations) => { const element = document.querySelector(selector); if (element) { observer.disconnect(); resolve(element); } }); observer.observe(document.body, { childList: true, subtree: true, }); // Timeout after 10 seconds if the element does not appear setTimeout(() => { observer.disconnect(); reject(new Error(`Element with selector "${selector}" did not appear within 10 seconds`)); }, 10000); }); } }); </script>  </div> </div> </div> <input type="hidden" name="12649.donation" id="12649.donation" value="form1" /> </div> <script type="text/javascript"> var submitted = false; function checkDoubleClick() { var elCheck = ''; if (elCheck == 'el') { alert ('Form submission is not enabled when previewing an individual data element.'); return false; } else if (submitted) { alert('You have already submitted this payment. 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