[give_form id="29882"]
<div id="give-form-29882-wrap" class="give-form-wrap give-display-button give-display-button-only give-recurring-form-wrap give-recurring-form-donor">
<h2 class="give-form-title">Leaders Speak about Meir Panim</h2><div id="give-form-content-29882" class="give-form-content-wrap give_pre_form-content"><div id="et-boc" class="et-boc">
<div class="et-l et-l--post">
<div class="et_builder_inner_content et_pb_gutters3">
</div><!-- .et_builder_inner_content -->
</div><!-- .et-l -->
</div><!-- #et-boc -->
</div> <form id="give-form-29882-2" class="give-form give-form-29882 give-form-type-multi float-labels-enabled give-recurring-form" action="https://give.meirpanim.org/passover-filled/?payment-mode=stripe" data-id="29882-2" data-currency_symbol="$" data-currency_code="USD" data-currency_position="before" data-thousands_separator="," data-decimal_separator="." data-number_decimals="2" data-publishable-key="pk_live_SMtnnvlq4TpJelMdklNha8iD" data-account="acct_1BwwETLjb9lKtTy7" data-give_cs_base_amounts="{"1":"54.00","3":"180.00","4":"540.00","5":"1000.00","custom":0}" method="post">
<!-- The following field is for robots only, invisible to humans: -->
<span class="give-hidden" style="display: none !important;">
<label for="give-form-honeypot-29882"></label>
<input id="give-form-honeypot-29882" type="text" name="give-honeypot"
class="give-honeypot give-hidden"/>
</span>
<input type="hidden" name="give-form-id-prefix" value="29882-2"/>
<input type="hidden" name="give-form-id" value="29882"/>
<input type="hidden" name="give-form-title" value="Leaders Speak about Meir Panim"/>
<input type="hidden" name="give-current-url" value="https://give.meirpanim.org/passover-filled/"/>
<input type="hidden" name="give-form-url" value="https://give.meirpanim.org/passover-filled/"/>
<input type="hidden" name="give-form-minimum"
value="5.00"/>
<input type="hidden" name="give-form-maximum"
value="999999.99"/>
<input type="hidden" name="give-form-hash" value="5ced51d635" data-time="1627594701" data-nonce-life="86400" data-donor-session="0"/><input type="hidden" name="give-price-id" value="1"/> <input type="hidden" name="give-recurring-logged-in-only"
class="give-recurring-logged-in-only"
value=""/>
<input type="hidden" name="give-logged-in-only"
class="give-logged-in-only"
value="1"/>
<input
type="hidden"
name="_give_is_donation_recurring"
class="_give_is_donation_recurring"
id="_give_is_donation_recurring"
value="1"
data-_give_recurring="yes_donor"
data-_give_checkbox_default="yes"
data-_give_price_option=""
/><input
type="hidden"
name="give_recurring_donation_details"
class="give_recurring_donation_details"
id="give_recurring_donation_details"
value="{"give_recurring_option":"yes_donor"}"
/> <div class="give-total-wrap">
<div class="give-donation-amount form-row-wide">
<span class="give-currency-symbol give-currency-position-before">$</span> <label class="give-hidden" for="give-amount">Donation Amount:</label>
<input class="give-text-input give-amount-top" id="give-amount" name="give-amount" type="tel"
placeholder="" value="54.00" autocomplete="off">
</div>
</div>
<fieldset
class="give-currency-switcher-wrap form-row form-row-wide"
data-give_form_id="29882">
<legend class="give-cs-msg-legend give-hidden"> </legend>
<select name="give-cs-currency" class="give-cs-select-currency give-hidden">
<option
value="USD" selected='selected'>
US Dollars </option>
<option
value="EUR" >
Euros </option>
<option
value="GBP" >
Pounds Sterling </option>
<option
value="AUD" >
Australian Dollars </option>
<option
value="BRL" >
Brazilian Real </option>
<option
value="CAD" >
Canadian Dollars </option>
<option
value="CZK" >
Czech Koruna </option>
<option
value="DKK" >
Danish Krone </option>
<option
value="HKD" >
Hong Kong Dollar </option>
<option
value="ILS" >
Israeli Shekel </option>
<option
value="NZD" >
New Zealand Dollar </option>
<option
value="ZAR" >
South African Rand </option>
<option
value="SEK" >
Swedish Krona </option>
<option
value="CHF" >
Swiss Franc </option>
<option
value="ANG" >
Netherlands Antillean guilder </option>
<option
value="CNY" >
Chinese yuan </option>
<option
value="XPF" >
CFP franc </option>
</select>
<input type="hidden" name="give-cs-base-currency" value="USD"/>
<input type="hidden" name="give-cs-exchange-rate" value="0"/>
<input type="hidden" name="give-cs-form-currency" value="USD"/>
<div
class="give-currency-switcher-msg-wrap give-hidden">
<span
class="give-currency-switcher-msg "
data-rawtext="The current exchange rate is 1.00 {base_currency} equals {new_currency_rate} {new_currency}.">
</span>
</div>
</fieldset>
<ul id="give-donation-level-button-wrap" class="give-donation-levels-wrap give-list-inline"><li><button type="button" data-price-id="1" class="give-donation-level-btn give-btn give-btn-level-1 give-default-level" value="54.00" data-default="1">$54</button></li><li><button type="button" data-price-id="3" class="give-donation-level-btn give-btn give-btn-level-3 " value="180.00" data-default="0">$180</button></li><li><button type="button" data-price-id="4" class="give-donation-level-btn give-btn give-btn-level-4 " value="540.00" data-default="0">$540</button></li><li><button type="button" data-price-id="5" class="give-donation-level-btn give-btn give-btn-level-5 " value="1,000.00" data-default="0">$1000</button></li><li><button type="button" data-price-id="custom" class="give-donation-level-btn give-btn give-btn-level-custom" value="custom">Custom Amount</button></li></ul> <input type="hidden" value="1" class="give-fee-disable"/>
<fieldset class="give-fee-recovery-donors-choice give-fee-message form-row"
id="give-fee-recovery-wrap-29882">
<legend class="give-fee-message-legend"
style="display: none;">Would you like to help cover the processing fees?</legend>
<label
for="give_fee_mode_checkbox-29882"
class="give-fee-message-label"
data-feemessage="I'd like to help cover the transaction fees of {fee_amount} for my donation."
style="font-weight:normal; cursor: pointer;"
>
<input
name="give_fee_mode_checkbox"
type="checkbox"
id="give_fee_mode_checkbox-29882"
class="give_fee_mode_checkbox"
value="0"
/>
<span class="give-fee-message-label-text">I'd like to help cover the transaction fees of 0 for my donation.</span>
</label>
</fieldset>
<div class="give-recurring-donors-choice">
<input id="give-admin_choice-29882" class="give-recurring-period" name="give-recurring-period" type="checkbox" data-period-label="Monthly" data-period="month" data-interval="1" checked /> <label for="give-admin_choice-29882">Help Israelis all year with a donation monthly</label> </div>
<input id="give-stripe-payment-method-29882-2" type="hidden" name="give_stripe_payment_method" value=""><input type="hidden" name="give-fee-recovery-settings" value="{"fee_data":{"all_gateways":{"percentage":"3.900000","base_amount":"0.300000","give_fee_disable":false,"give_fee_status":true,"is_break_down":true,"maxAmount":0}},"give_fee_status":true,"give_fee_disable":false,"is_break_down":true,"fee_mode":"donor_opt_in","is_fee_mode":true,"fee_recovery":true}" />
<fieldset id="give-payment-mode-select"
>
<legend
class="give-payment-mode-label">Select Payment Method <span class="give-loading-text"><span
class="give-loading-animation"></span>
</span>
</legend>
<div id="give-payment-mode-wrap">
<ul id="give-gateway-radio-list">
<li class="give-gateway-option-selected">
<input type="radio" name="payment-mode" class="give-gateway"
id="give-gateway-stripe-29882-2"
value="stripe" checked='checked'>
<label for="give-gateway-stripe-29882-2"
class="give-gateway-option"
id="give-gateway-option-stripe"> Credit/Debit Card</label>
</li>
<li>
<input type="radio" name="payment-mode" class="give-gateway"
id="give-gateway-paypal-29882-2"
value="paypal">
<label for="give-gateway-paypal-29882-2"
class="give-gateway-option"
id="give-gateway-option-paypal"> PayPal</label>
</li>
</ul>
</div>
</fieldset>
<div id="give_purchase_form_wrap">
<fieldset id="give_checkout_user_info" class="">
<legend>
Personal Info </legend>
<p id="give-first-name-wrap" class="form-row form-row-first form-row-responsive">
<label class="give-label" for="give-first">
First Name <span class="give-required-indicator">*</span>
<span class="give-tooltip hint--top hint--medium hint--bounce" aria-label="First Name is used to personalize your donation record." rel="tooltip"><i class="give-icon give-icon-question"></i></span> </label>
<input
class="give-input required"
type="text"
name="give_first"
autocomplete="given-name"
placeholder="First Name"
id="give-first"
value=""
required aria-required="true" />
</p>
<p id="give-last-name-wrap" class="form-row form-row-last form-row-responsive">
<label class="give-label" for="give-last">
Last Name <span class="give-required-indicator">*</span>
<span class="give-tooltip hint--top hint--medium hint--bounce" aria-label="Last Name is used to personalize your donation record." rel="tooltip"><i class="give-icon give-icon-question"></i></span> </label>
<input
class="give-input required"
type="text"
name="give_last"
autocomplete="family-name"
id="give-last"
placeholder="Last Name"
value=""
required aria-required="true" />
</p>
<p id="give-email-wrap" class="form-row form-row-wide">
<label class="give-label" for="give-email">
Email Address <span class="give-required-indicator">*</span>
<span class="give-tooltip hint--top hint--medium hint--bounce" aria-label="We will send the donation receipt to this address." rel="tooltip"><i class="give-icon give-icon-question"></i></span> </label>
<input
class="give-input required"
type="email"
name="give_email"
autocomplete="email"
placeholder="Email Address"
id="give-email"
value=""
required aria-required="true" />
</p>
</fieldset>
<fieldset id="give-ffm-section" data-fields="mailing_address|city|state|zip_code|country|home_phone_number|cell_phone_number">
<div id="mailing_address-wrap" class="form-row give-ffm-form-row-responsive give-ffm-form-row-full "><label class="give-label" for="ffm-mailing_address">Mailing Address </label> <input class="textfield"
id="ffm-mailing_address" type="text"
data-required="no"
data-type="text" name="mailing_address"
placeholder="" value=""
/>
</div><div id="city-wrap" class="form-row give-ffm-form-row-responsive give-ffm-form-row-one-third "><label class="give-label" for="ffm-city">City </label> <input class="textfield"
id="ffm-city" type="text"
data-required="no"
data-type="text" name="city"
placeholder="" value=""
/>
</div><div id="state-wrap" class="form-row give-ffm-form-row-responsive give-ffm-form-row-one-third "><label class="give-label" for="ffm-state">State </label> <input class="textfield"
id="ffm-state" type="text"
data-required="no"
data-type="text" name="state"
placeholder="" value=""
/>
</div><div id="zip_code-wrap" class="form-row give-ffm-form-row-responsive give-ffm-form-row-one-third "><label class="give-label" for="ffm-zip_code">Zip Code </label> <input class="textfield"
id="ffm-zip_code" type="text"
data-required="no"
data-type="text" name="zip_code"
placeholder="" value=""
/>
</div><div id="country-wrap" class="form-row give-ffm-form-row-responsive give-ffm-form-row-full "><label class="give-label" for="ffm-country">Country </label> <input class="textfield"
id="ffm-country" type="text"
data-required="no"
data-type="text" name="country"
placeholder="" value=""
/>
</div><div id="home_phone_number-wrap" class="form-row give-ffm-form-row-responsive give-ffm-form-row-half "><label class="give-label" for="ffm-home_phone_number">Home Phone Number </label>
<input
class="phone"
id="ffm-home_phone_number" type="tel"
data-required="no"
data-type="tel" name="home_phone_number"
placeholder="" value=""/>
</div><div id="cell_phone_number-wrap" class="form-row give-ffm-form-row-responsive give-ffm-form-row-half "><label class="give-label" for="ffm-cell_phone_number">Cell Phone Number </label>
<input
class="phone js-phone-domestic"
id="ffm-cell_phone_number" type="tel"
data-required="no"
data-type="tel" name="cell_phone_number"
placeholder="" value=""/>
</div> <input class="hiddenfield"
id="ffm-page_url" type="hidden"
name="page_url"
value=""/>
</fieldset>
<fieldset id="give_cc_fields" class="give-do-validate">
<legend>
Credit/Debit Card Info
</legend>
<div id="give_secure_site_wrapper">
<span class="give-icon padlock"></span>
<span>
This is a secure SSL encrypted payment. </span>
</div>
<div id="give-card-number-wrap-29882-2" class="form-row form-row-two-thirds form-row-responsive give-stripe-cc-field-wrap">
<div>
<label for="give-card-number-field-29882-2" class="give-label">
Card Number <span class="give-required-indicator">*</span>
<span class="give-tooltip give-icon give-icon-question"
data-tooltip="The (typically) 16 digits on the front of your credit card."></span>
<span class="card-type"></span>
</label>
<div id="give-card-number-field-29882-2" class="input empty give-stripe-cc-field give-stripe-card-number-field"></div>
</div>
</div>
<div id="give-card-cvc-wrap-29882-2" class="form-row form-row-one-third form-row-responsive give-stripe-cc-field-wrap">
<div>
<label for="give-card-cvc-field-29882-2" class="give-label">
CVC <span class="give-required-indicator">*</span>
<span class="give-tooltip give-icon give-icon-question"
data-tooltip="The 3 digit (back) or 4 digit (front) value on your card."></span>
</label>
<div id="give-card-cvc-field-29882-2" class="input empty give-stripe-cc-field give-stripe-card-cvc-field"></div>
</div>
</div>
<div id="give-card-name-wrap-29882-2" class="form-row form-row-two-thirds form-row-responsive">
<label for="give-card-name-field-29882-2" class="give-label">
Cardholder Name <span class="give-required-indicator">*</span>
<span class="give-tooltip give-icon give-icon-question"
data-tooltip="The name of the credit card account holder."></span>
</label>
<input
type="text"
autocomplete="off"
id="give-card-name-field-29882-2"
name="card_name"
class="card-name give-input required"
placeholder="Cardholder Name"
/>
</div>
<div id="give-card-expiration-wrap-29882-2" class="card-expiration form-row form-row-one-third form-row-responsive give-stripe-cc-field-wrap">
<div>
<label for="give-card-expiration-field-29882-2" class="give-label">
Expiration <span class="give-required-indicator">*</span>
<span class="give-tooltip give-icon give-icon-question"
data-tooltip="The date your credit card expires, typically on the front of the card."></span>
</label>
<div id="give-card-expiration-field-29882-2" class="input empty give-stripe-cc-field give-stripe-card-expiration-field"></div>
</div>
</div>
</fieldset>
<fieldset id="give-tributes-dedicate-donation-29882" class="give-tributes-dedicate-donation"> <!-- Give - Tributes Start -->
<input type="hidden" class="give-tributes-type" name="give_tributes_type" value="In Honor Of" />
<legend>Dedicate this Donation</legend>
<div id="give-tributes-options-29882">
<ul id="give-tributes-show-wrap-29882" class="give-tributes-show-wrap">
<li class="give-tributes-show-wrap-li">
<input
class="give-input"
type="radio"
id="give-tributes-yes-29882"
name="give_tributes_show_dedication"
value="yes"
/>
<label for="give-tributes-yes-29882" class="give-tributes-yes"> Yes, please</label>
</li>
<li class="give-tributes-show-wrap-li">
<input
class="give-input"
type="radio"
id="give-tributes-no-29882"
name="give_tributes_show_dedication"
checked="checked"
value="no"
/>
<label for="give-tributes-no-29882" class="give-tributes-no"> No, thank you</label>
</li>
</ul>
</div>
<div id="give-tributes-type-wrap-29882" class="has_radios give_tributes_type_wrap"> <!-- Give - Tributes type wrap start --><label class="give-tributes-label" for="give-tribute-type-29882" id="give-tribute-type-29882">Dedication Type</label><ul id="give-tributes-type-radio-list-29882" class="give-tribute-radio-ul"><li><input type="radio" id="give-tributes-type-radio-in-honor-of-29882" name="give_tributes_radio_type" data-tribute-type="In Honor Of" class="give-tribute-type-radio" value="In Honor Of" checked="checked"><label for="give-tributes-type-radio-in-honor-of-29882" class="give-tributes-type-radio">In Honor Of</label></li><li><input type="radio" id="give-tributes-type-radio-in-memory-of-29882" name="give_tributes_radio_type" data-tribute-type="In Memory Of" class="give-tribute-type-radio" value="In Memory Of" ><label for="give-tributes-type-radio-in-memory-of-29882" class="give-tributes-type-radio">In Memory Of</label></li><li><input type="radio" id="give-tributes-type-radio-get-well-soon-for-29882" name="give_tributes_radio_type" data-tribute-type="Get Well Soon For" class="give-tribute-type-radio" value="Get Well Soon For" ><label for="give-tributes-type-radio-get-well-soon-for-29882" class="give-tributes-type-radio">Get Well Soon For</label></li></ul></div> <!-- Give - Tributes type wrap end --> <div id="give-tributes-info-wrap-29882" class="give_tributes_info_wrap"><!-- Give - Tributes Info Wrap Start -->
<h3 class="give-section-break give-tributes-legend">Honoree Details</h3>
<p id="give-tributes-first-name-wrap-29882" class="form-row form-row-first form-row-responsive">
<label class="give-label" for="give-tributes-first-name-29882">
First Name
<span class="give-required-indicator">*</span>
<span class="give-tooltip give-icon give-icon-question"
data-tooltip="The first name of the honoree."></span>
</label>
<input
class="give-input required"
type="text"
name="give_tributes_first_name"
placeholder="Honoree First Name"
id="give-tributes-first-name-29882"
value=""
/>
</p>
<p id="give-tributes-last-name-wrap-29882" class="form-row form-row-last form-row-responsive">
<label class="give-label" for="give-tributes-last-name-29882">
Last Name <span class="give-tooltip give-icon give-icon-question"
data-tooltip="The last name of the honoree."></span>
</label>
<input
class="give-input "
type="text"
name="give_tributes_last_name"
placeholder="Honoree Last Name"
id="give-tributes-last-name-29882"
value=""
/>
</p>
</div><!-- Give - Tributes Info Wrap End -->
<div id="give-tributes-grab-info-wrap-29882" class="give_tributes_grab_info_wrap"><!-- Give - Tributes Grab Info Start -->
<label for="i-would-like-to"
class="give-tribute-type give-tributes-label">Would you like us to notify anyone of your donation?</label>
<ul id="give-tributes-grab-info-29882" class="give-tributes-grab-info">
<li>
<input
class="give-input"
id="give-tributes-mail-a-card-29882"
type="radio" name="give_tributes_would_to"
value="send_mail_card"
/>
<label for="give-tributes-mail-a-card-29882"
class="give-tributes-would-to"> Yes, mail a card</label>
</li>
<li>
<input
class="give-input"
id="give-tributes-send-an-ecard-29882"
type="radio"
name="give_tributes_would_to"
value="send_eCard"
/>
<label for="give-tributes-send-an-ecard-29882"
class="give-tributes-would-to"> Yes, send an eCard</label>
</li>
<li>
<input
class="give-input"
id="give-tributes-none-29882"
type="radio"
name="give_tributes_would_to"
checked="checked"
value="none"
/>
<label for="give-tributes-none-29882"
class="give-tributes-would-to"> No thanks</label>
</li>
</ul>
</div><!-- Give - Tributes Info Wrap End -->
<div class="give-tributes-notification-lists" id="give-tributes-notification-list-29882"><!-- Give - Tributes eCard Notification list Start -->
<div id="give-tributes-send-ecard-fields-29882" class="give_tributes_send_ecard_fields"><!-- Give - Tributes eCard Fields Start -->
<h3 class="give-section-break give-tributes-legend">Notification Details <div class="give-tributes-add-recipient">
<span data-tooltip="Add Notification" class="give-tributes-clone-field give-tooltip" data-action="add"><span
class="give-icon give-icon-plus"></span></span>
<span href="javascript:void(0);" data-tooltip="Remove this notification" class="give-tributes-clone-field give-tooltip"
data-action="remove"><span class="give-icon give-icon-minus"></span></span>
</div>
</h3>
<div id="give-tributes-ecard-personalized-message-29882"
class="form-row form-row-responsive give_tributes_ecard_personalized_message">
<label class="give-label" for="give-tributes-ecard-personalized-message-area-29882">
Personalized Message
<span class="give-required-indicator">*</span>
<span class="give-tooltip give-icon give-icon-question"
data-tooltip="This is the personalized notification message that is sent to the recipient."></span>
</label>
<textarea
maxlength="1255"
name="give_tributes_ecard_notify[recipient][personalized][]"
id="give-tributes-ecard-personalized-message-area-29882"
class="give-tributes-personalized-message large-text"></textarea>
<span id="give-tributes-ecard-personalized-message-left-29882"
class="give-tributes-ecard-personalized-message-left">1255 Characters left</span>
</div>
<div id="give-tributes-ecard-notify-first-name-wrap-29882" class="form-row form-row-first form-row-responsive">
<label class="give-label" for="give-tributes-ecard-notify-first-name-29882">
First Name
<span class="give-required-indicator">*</span>
<span class="give-tooltip give-icon give-icon-question"
data-tooltip="The first name of the recipient."></span>
</label>
<input
class="give-input required"
type="text"
name="give_tributes_ecard_notify[recipient][first_name][]"
placeholder="Recipient First Name"
id="give-tributes-ecard-notify-first-name-29882"
value=""
/>
</div>
<div id="give-tributes-ecard-notify-last-name-wrap-29882" class="form-row form-row-last form-row-responsive">
<label class="give-label" for="give-tributes-ecard-notify-last-name-29882">
Last Name <span class="give-tooltip give-icon give-icon-question"
data-tooltip="The last name of the recipient."></span>
</label>
<input
class="give-input "
type="text"
name="give_tributes_ecard_notify[recipient][last_name][]"
placeholder="Recipient Last Name"
id="give-tributes-ecard-notify-last-name-29882"
value=""
/>
</div>
<div id="give-tributes-ecard-email-29882" class="form-row form-row-wide form-row-responsive give_tributes_ecard_email">
<label class="give-label" for="give-tributes-send-ecard-email-29882">
Email Address <span class="give-required-indicator">*</span>
<span class="give-tooltip give-icon give-icon-question" data-tooltip="This is the email address of the notification recipient."></span>
</label>
<input
class="give-input required"
type="email"
name="give_tributes_ecard_notify[recipient][email][]"
placeholder="Recipient Email Address"
id="give-tributes-send-ecard-email-29882"
value=""
/>
</div>
</div><!-- Give - Tributes eCard Fields End -->
</div><!-- Give - Tributes eCard Notification list End -->
<div id="give-tributes-mail-card-fields-29882" class="give_tributes_mail_card_fields"><!-- Give - Tributes Mail a Card Fields Start -->
<h3 class="give-section-break give-tributes-legend">Notification Details</h3>
<p id="give-tributes-mail-card-personalized-message-29882"
class="form-row form-row-wide form-row-responsive give_tributes_mail_card_personalized_message">
<label class="give-label" for="give-tributes-mail-card-personalized-message-area-29882">
Personalized Message
<span class="give-required-indicator">*</span>
<span
class="give-tooltip give-icon give-icon-question"
data-tooltip="This is the personalized notification message that is sent inside the card.">
</span>
</label>
<textarea
maxlength="1255"
name="give-tributes-mail-card-personalized-message"
id="give-tributes-mail-card-personalized-message-area-29882"
class="large-text required"></textarea>
<span
id="give-tributes-mail-card-personalized-message-left-29882"
class="give-tributes-mail-card-personalized-message-left">
1255 Characters left </span>
</p>
<p id="give-tributes-mail-card-notify-first-name-wrap-29882" class="form-row form-row-first form-row-responsive">
<label class="give-label" for="give-tributes-mail-card-notify-first-name-29882">
First Name <span class="give-required-indicator">*</span>
<span class="give-tooltip give-icon give-icon-question"
data-tooltip="The first name of the recipient being notifed of your donation."></span>
</label>
<input
class="give-input required"
type="text"
name="give_tributes_mail_card_notify_first_name"
placeholder="Recipient First Name"
id="give-tributes-mail-card-notify-first-name-29882"
value=""
/>
</p>
<p id="give-tributes-mail-card-notify-last-name-wrap-29882" class="form-row form-row-last form-row-responsive">
<label class="give-label" for="give-tributes-mail-card-notify-last-name-29882">
Last Name <span class="give-tooltip give-icon give-icon-question"
data-tooltip="The last name of the recipient being notifed of your donation."></span>
</label>
<input
class="give-input "
type="text"
name="give_tributes_mail_card_notify_last_name"
placeholder="Recipient Last Name"
id="give-tributes-mail-card-notify-last-name-29882"
value=""
/>
</p>
<p id="give-tributes-mail-card-country-29882"
class="form-row form-row-wide form-row-responsive give_tributes_mail_card_country">
<label for="give_tributes_address_country_29882">
Country <span class="give-required-indicator">*</span>
<span class="give-tooltip give-icon give-icon-question" data-tooltip="The recipient's country."></span>
</label>
<select
name="give_tributes_address_country"
id="give_tributes_address_country_29882"
class="select give-select required">
<option value="US" selected='selected'>United States</option>
<option value="CA" >Canada</option>
<option value="GB" >United Kingdom</option>
<option value="AF" >Afghanistan</option>
<option value="AL" >Albania</option>
<option value="DZ" >Algeria</option>
<option value="AS" >American Samoa</option>
<option value="AD" >Andorra</option>
<option value="AO" >Angola</option>
<option value="AI" >Anguilla</option>
<option value="AQ" >Antarctica</option>
<option value="AG" >Antigua and Barbuda</option>
<option value="AR" >Argentina</option>
<option value="AM" >Armenia</option>
<option value="AW" >Aruba</option>
<option value="AU" >Australia</option>
<option value="AT" >Austria</option>
<option value="AZ" >Azerbaijan</option>
<option value="BS" >Bahamas</option>
<option value="BH" >Bahrain</option>
<option value="BD" >Bangladesh</option>
<option value="BB" >Barbados</option>
<option value="BY" >Belarus</option>
<option value="BE" >Belgium</option>
<option value="BZ" >Belize</option>
<option value="BJ" >Benin</option>
<option value="BM" >Bermuda</option>
<option value="BT" >Bhutan</option>
<option value="BO" >Bolivia</option>
<option value="BA" >Bosnia and Herzegovina</option>
<option value="BW" >Botswana</option>
<option value="BV" >Bouvet Island</option>
<option value="BR" >Brazil</option>
<option value="IO" >British Indian Ocean Territory</option>
<option value="BN" >Brunei Darrussalam</option>
<option value="BG" >Bulgaria</option>
<option value="BF" >Burkina Faso</option>
<option value="BI" >Burundi</option>
<option value="KH" >Cambodia</option>
<option value="CM" >Cameroon</option>
<option value="CV" >Cape Verde</option>
<option value="KY" >Cayman Islands</option>
<option value="CF" >Central African Republic</option>
<option value="TD" >Chad</option>
<option value="CL" >Chile</option>
<option value="CN" >China</option>
<option value="CX" >Christmas Island</option>
<option value="CC" >Cocos Islands</option>
<option value="CO" >Colombia</option>
<option value="KM" >Comoros</option>
<option value="CD" >Congo, Democratic People's Republic</option>
<option value="CG" >Congo, Republic of</option>
<option value="CK" >Cook Islands</option>
<option value="CR" >Costa Rica</option>
<option value="CI" >Cote d'Ivoire</option>
<option value="HR" >Croatia/Hrvatska</option>
<option value="CU" >Cuba</option>
<option value="CY" >Cyprus Island</option>
<option value="CZ" >Czech Republic</option>
<option value="DK" >Denmark</option>
<option value="DJ" >Djibouti</option>
<option value="DM" >Dominica</option>
<option value="DO" >Dominican Republic</option>
<option value="TP" >East Timor</option>
<option value="EC" >Ecuador</option>
<option value="EG" >Egypt</option>
<option value="GQ" >Equatorial Guinea</option>
<option value="SV" >El Salvador</option>
<option value="ER" >Eritrea</option>
<option value="EE" >Estonia</option>
<option value="ET" >Ethiopia</option>
<option value="FK" >Falkland Islands</option>
<option value="FO" >Faroe Islands</option>
<option value="FJ" >Fiji</option>
<option value="FI" >Finland</option>
<option value="FR" >France</option>
<option value="GF" >French Guiana</option>
<option value="PF" >French Polynesia</option>
<option value="TF" >French Southern Territories</option>
<option value="GA" >Gabon</option>
<option value="GM" >Gambia</option>
<option value="GE" >Georgia</option>
<option value="DE" >Germany</option>
<option value="GR" >Greece</option>
<option value="GH" >Ghana</option>
<option value="GI" >Gibraltar</option>
<option value="GL" >Greenland</option>
<option value="GD" >Grenada</option>
<option value="GP" >Guadeloupe</option>
<option value="GU" >Guam</option>
<option value="GT" >Guatemala</option>
<option value="GG" >Guernsey</option>
<option value="GN" >Guinea</option>
<option value="GW" >Guinea-Bissau</option>
<option value="GY" >Guyana</option>
<option value="HT" >Haiti</option>
<option value="HM" >Heard and McDonald Islands</option>
<option value="VA" >Holy See (City Vatican State)</option>
<option value="HN" >Honduras</option>
<option value="HK" >Hong Kong</option>
<option value="HU" >Hungary</option>
<option value="IS" >Iceland</option>
<option value="IN" >India</option>
<option value="ID" >Indonesia</option>
<option value="IR" >Iran</option>
<option value="IQ" >Iraq</option>
<option value="IE" >Ireland</option>
<option value="IM" >Isle of Man</option>
<option value="IL" >Israel</option>
<option value="IT" >Italy</option>
<option value="JM" >Jamaica</option>
<option value="JP" >Japan</option>
<option value="JE" >Jersey</option>
<option value="JO" >Jordan</option>
<option value="KZ" >Kazakhstan</option>
<option value="KE" >Kenya</option>
<option value="KI" >Kiribati</option>
<option value="KW" >Kuwait</option>
<option value="KG" >Kyrgyzstan</option>
<option value="LA" >Lao People's Democratic Republic</option>
<option value="LV" >Latvia</option>
<option value="LB" >Lebanon</option>
<option value="LS" >Lesotho</option>
<option value="LR" >Liberia</option>
<option value="LY" >Libyan Arab Jamahiriya</option>
<option value="LI" >Liechtenstein</option>
<option value="LT" >Lithuania</option>
<option value="LU" >Luxembourg</option>
<option value="MO" >Macau</option>
<option value="MK" >Macedonia</option>
<option value="MG" >Madagascar</option>
<option value="MW" >Malawi</option>
<option value="MY" >Malaysia</option>
<option value="MV" >Maldives</option>
<option value="ML" >Mali</option>
<option value="MT" >Malta</option>
<option value="MH" >Marshall Islands</option>
<option value="MQ" >Martinique</option>
<option value="MR" >Mauritania</option>
<option value="MU" >Mauritius</option>
<option value="YT" >Mayotte</option>
<option value="MX" >Mexico</option>
<option value="FM" >Micronesia</option>
<option value="MD" >Moldova, Republic of</option>
<option value="MC" >Monaco</option>
<option value="MN" >Mongolia</option>
<option value="ME" >Montenegro</option>
<option value="MS" >Montserrat</option>
<option value="MA" >Morocco</option>
<option value="MZ" >Mozambique</option>
<option value="MM" >Myanmar</option>
<option value="NA" >Namibia</option>
<option value="NR" >Nauru</option>
<option value="NP" >Nepal</option>
<option value="NL" >Netherlands</option>
<option value="AN" >Netherlands Antilles</option>
<option value="NC" >New Caledonia</option>
<option value="NZ" >New Zealand</option>
<option value="NI" >Nicaragua</option>
<option value="NE" >Niger</option>
<option value="NG" >Nigeria</option>
<option value="NU" >Niue</option>
<option value="NF" >Norfolk Island</option>
<option value="KP" >North Korea</option>
<option value="MP" >Northern Mariana Islands</option>
<option value="NO" >Norway</option>
<option value="OM" >Oman</option>
<option value="PK" >Pakistan</option>
<option value="PW" >Palau</option>
<option value="PS" >Palestinian Territories</option>
<option value="PA" >Panama</option>
<option value="PG" >Papua New Guinea</option>
<option value="PY" >Paraguay</option>
<option value="PE" >Peru</option>
<option value="PH" >Philippines</option>
<option value="PN" >Pitcairn Island</option>
<option value="PL" >Poland</option>
<option value="PT" >Portugal</option>
<option value="PR" >Puerto Rico</option>
<option value="QA" >Qatar</option>
<option value="RE" >Reunion Island</option>
<option value="RO" >Romania</option>
<option value="RU" >Russian Federation</option>
<option value="RW" >Rwanda</option>
<option value="SH" >Saint Helena</option>
<option value="KN" >Saint Kitts and Nevis</option>
<option value="LC" >Saint Lucia</option>
<option value="PM" >Saint Pierre and Miquelon</option>
<option value="VC" >Saint Vincent and the Grenadines</option>
<option value="SM" >San Marino</option>
<option value="ST" >Sao Tome and Principe</option>
<option value="SA" >Saudi Arabia</option>
<option value="SN" >Senegal</option>
<option value="RS" >Serbia</option>
<option value="SC" >Seychelles</option>
<option value="SL" >Sierra Leone</option>
<option value="SG" >Singapore</option>
<option value="SK" >Slovak Republic</option>
<option value="SI" >Slovenia</option>
<option value="SB" >Solomon Islands</option>
<option value="SO" >Somalia</option>
<option value="ZA" >South Africa</option>
<option value="GS" >South Georgia</option>
<option value="KR" >South Korea</option>
<option value="ES" >Spain</option>
<option value="LK" >Sri Lanka</option>
<option value="SD" >Sudan</option>
<option value="SR" >Suriname</option>
<option value="SJ" >Svalbard and Jan Mayen Islands</option>
<option value="SZ" >Eswatini</option>
<option value="SE" >Sweden</option>
<option value="CH" >Switzerland</option>
<option value="SY" >Syrian Arab Republic</option>
<option value="TW" >Taiwan</option>
<option value="TJ" >Tajikistan</option>
<option value="TZ" >Tanzania</option>
<option value="TG" >Togo</option>
<option value="TK" >Tokelau</option>
<option value="TO" >Tonga</option>
<option value="TH" >Thailand</option>
<option value="TT" >Trinidad and Tobago</option>
<option value="TN" >Tunisia</option>
<option value="TR" >Turkey</option>
<option value="TM" >Turkmenistan</option>
<option value="TC" >Turks and Caicos Islands</option>
<option value="TV" >Tuvalu</option>
<option value="UG" >Uganda</option>
<option value="UA" >Ukraine</option>
<option value="AE" >United Arab Emirates</option>
<option value="UY" >Uruguay</option>
<option value="UM" >US Minor Outlying Islands</option>
<option value="UZ" >Uzbekistan</option>
<option value="VU" >Vanuatu</option>
<option value="VE" >Venezuela</option>
<option value="VN" >Vietnam</option>
<option value="VG" >Virgin Islands (British)</option>
<option value="VI" >Virgin Islands (USA)</option>
<option value="WF" >Wallis and Futuna Islands</option>
<option value="EH" >Western Sahara</option>
<option value="WS" >Western Samoa</option>
<option value="YE" >Yemen</option>
<option value="YU" >Yugoslavia</option>
<option value="ZM" >Zambia</option>
<option value="ZW" >Zimbabwe</option>
</select>
</p>
<p id="give-tributes-mail-card-address1-29882"
class="form-row form-row-wide form-row-responsive give_tributes_mail_card_address1">
<label class="give-label" for="give-tributes-mail-card-address1-29882">
Address Line 1
<span class="give-required-indicator">*</span>
<span
class="give-tooltip give-icon give-icon-question"
data-tooltip="The recipient's mailing address.">
</span>
</label>
<input
class="give-input give_tributes_mail_card_address_1 required"
type="text"
name="give_tributes_mail_card_address_1"
placeholder="Recipient Address Line 1"
id="give-tributes-mail-card-address1-29882"
value=""
/>
</p>
<p id="give-tributes-mail-card-address2-29882"
class="form-row form-row-responsive form-row-wide give_tributes_mail_card_address2">
<label class="give-label" for="give-tributes-mail-card-address2-29882">
Address Line 2 <span
class="give-tooltip give-icon give-icon-question"
data-tooltip="Additional address information for the recipient.">
</span>
</label>
<input
class="give-input give_tributes_mail_card_address_2"
type="text"
name="give_tributes_mail_card_address_2"
placeholder="Recipient Address Line 2"
id="give-tributes-mail-card-address2-29882"
value=""
/>
</p>
<p id="give-tributes-mail-card-city-29882"
class="form-row form-row-responsive give_tributes_mail_card_city form-row-wide">
<label class="give-label" for="give-tributes-mail-card-city-29882">
City
<span class="give-required-indicator">*</span>
<span
class="give-tooltip give-icon give-icon-question"
data-tooltip="The recipient's city.">
</span>
</label>
<input
class="give-input required"
type="text"
name="give_tributes_mail_card_city"
placeholder="Recipient City"
id="give-tributes-mail-card-city-29882"
value=""
/>
</p>
<p id="give-tributes-mail-card-state-29882"
class="form-row form-row-responsive give_tributes_mail_card_state form-row-first ">
<label class="give_tributes_address_state_label" for="give_tributes_address_state_29882">
State <span class="give-required-indicator">*</span>
<span
class="give-tooltip give-icon give-icon-question"
data-tooltip="The recipient's state, province, or county.">
</span>
</label>
<select data-key="state" name="give_tributes_address_state" id="give_tributes_address_state_29882" class="text give-input required">
<option value="" selected='selected'></option><option value="AL">Alabama</option><option value="AK">Alaska</option><option value="AZ">Arizona</option><option value="AR">Arkansas</option><option value="CA">California</option><option value="CO">Colorado</option><option value="CT">Connecticut</option><option value="DE">Delaware</option><option value="DC">District of Columbia</option><option value="FL">Florida</option><option value="GA">Georgia</option><option value="HI">Hawaii</option><option value="ID">Idaho</option><option value="IL">Illinois</option><option value="IN">Indiana</option><option value="IA">Iowa</option><option value="KS">Kansas</option><option value="KY">Kentucky</option><option value="LA">Louisiana</option><option value="ME">Maine</option><option value="MD">Maryland</option><option value="MA">Massachusetts</option><option value="MI">Michigan</option><option value="MN">Minnesota</option><option value="MS">Mississippi</option><option value="MO">Missouri</option><option value="MT">Montana</option><option value="NE">Nebraska</option><option value="NV">Nevada</option><option value="NH">New Hampshire</option><option value="NJ">New Jersey</option><option value="NM">New Mexico</option><option value="NY">New York</option><option value="NC">North Carolina</option><option value="ND">North Dakota</option><option value="OH">Ohio</option><option value="OK">Oklahoma</option><option value="OR">Oregon</option><option value="PA">Pennsylvania</option><option value="RI">Rhode Island</option><option value="SC">South Carolina</option><option value="SD">South Dakota</option><option value="TN">Tennessee</option><option value="TX">Texas</option><option value="UT">Utah</option><option value="VT">Vermont</option><option value="VA">Virginia</option><option value="WA">Washington</option><option value="WV">West Virginia</option><option value="WI">Wisconsin</option><option value="WY">Wyoming</option><option value="AS">American Samoa</option><option value="CZ">Canal Zone</option><option value="CM">Commonwealth of the Northern Mariana Islands</option><option value="FM">Federated States of Micronesia</option><option value="GU">Guam</option><option value="MH">Marshall Islands</option><option value="MP">Northern Mariana Islands</option><option value="PW">Palau</option><option value="PI">Philippine Islands</option><option value="PR">Puerto Rico</option><option value="TT">Trust Territory of the Pacific Islands</option><option value="VI">Virgin Islands</option><option value="AA">Armed Forces - Americas</option><option value="AE">Armed Forces - Europe, Canada, Middle East, Africa</option><option value="AP">Armed Forces - Pacific</option> </select>
</p>
<p id="give-tributes-mail-card-zipcode-29882"
class="form-row form-row-responsive give_tributes_mail_card_zipcode form-row-last give_tributes_adjust_zip">
<label class="give-label" for="give-tributes-mail-card-zipcode-29882">
Zip/Postal Code
<span class="give-required-indicator">*</span>
<span
class="give-tooltip give-icon give-icon-question"
data-tooltip="The recipient's zip or postal code.">
</span>
</label>
<input
class="give-input required"
type="text"
name="give_tributes_mail_card_zipcode"
placeholder="Recipient Zip/Postal Code"
id="give-tributes-mail-card-zipcode-29882"
value=""
/>
</p>
</div><!-- Give - Tributes Mail a Card Fields End -->
</fieldset> <!-- Give - Tributes End -->
<div id="give-stripe-payment-errors-29882-2"></div> <fieldset id="give_purchase_submit" class="give-donation-submit">
<p id="give-final-total-wrap" class="form-wrap ">
<span class="give-donation-total-label">
Total: </span>
<span class="give-final-total-amount"
data-total="54.00">
$54.00 </span>
<span id="give-recurring-modal-period-wrap" class=""><span id="give-recurring-modal-period">Monthly</span></span> </p>
<p class="fee-break-down-message fee-break-down-message-29882" data-breakdowntext="{amount} donation plus {fee_amount} to help cover fees." style="display: none;">{amount} donation plus {fee_amount} to help cover fees.</p> <input type="hidden" name="give_action" value="purchase"/>
<input type="hidden" name="give-gateway" value="stripe"/>
<div class="give-submit-button-wrap give-clearfix">
<input type="submit" class="give-submit give-btn" id="give-purchase-button" name="give-purchase"
value="I WANT TO GIVE" data-before-validation-label="I WANT TO GIVE"/>
<span class="give-loading-animation"></span>
</div>
</fieldset>
</div>
<div id="give-stripe-ideal-donation-errors"></div> </form>
<button type="button" class="give-btn give-btn-modal">OR, CLICK HERE TO MAKE A DONATION UNDER $100</button>
</div><!--end #give-form-29882-->
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