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<p style="margin: 0px 0px 1em; box-sizing: border-box; font-family: Arial; line-height: 25.2px;">Thanks for being a part of Chabad and sharing in our vision. Your donation enables us to offer an array of local programming throughout the year! </p>
<p style="margin: 0px 0px 1em; box-sizing: border-box; font-family: Arial; line-height: 25.2px;"><span data-scayt-word="Chabad" data-wsc-lang="en_US" data-wsc-id="mis9pe7jw7762qjiv">Chabad</span> Maimonides of Larchmont is a 501(C)3 Organization - EIN # 92-1512081</p>
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<label for="input_10" style="box-sizing: border-box; font-weight: 700;">Address<span class="form-required" style="box-sizing: border-box; margin-left: 5px; color: red;">*</span></label></div>
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<td width="50%" style="box-sizing: border-box; padding-bottom: 10px;">
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<td style="box-sizing: border-box; padding-bottom: 10px; text-align: right; padding-left: 10px;">
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<td style="box-sizing: border-box; padding-bottom: 10px; text-align: right; padding-left: 10px;">
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<option value="" selected style="box-sizing: border-box;">Please Select</option>
<option selected value="United States" style="box-sizing: border-box;">United States</option>
<option value="Afghanistan" style="box-sizing: border-box;">Afghanistan</option>
<option value="Albania" style="box-sizing: border-box;">Albania</option>
<option value="Algeria" style="box-sizing: border-box;">Algeria</option>
<option value="American Samoa" style="box-sizing: border-box;">American Samoa</option>
<option value="Andorra" style="box-sizing: border-box;">Andorra</option>
<option value="Angola" style="box-sizing: border-box;">Angola</option>
<option value="Anguilla" style="box-sizing: border-box;">Anguilla</option>
<option value="Antigua and Barbuda" style="box-sizing: border-box;">Antigua and Barbuda</option>
<option value="Argentina" style="box-sizing: border-box;">Argentina</option>
<option value="Armenia" style="box-sizing: border-box;">Armenia</option>
<option value="Aruba" style="box-sizing: border-box;">Aruba</option>
<option value="Australia" style="box-sizing: border-box;">Australia</option>
<option value="Austria" style="box-sizing: border-box;">Austria</option>
<option value="Azerbaijan" style="box-sizing: border-box;">Azerbaijan</option>
<option value="The Bahamas" style="box-sizing: border-box;">The Bahamas</option>
<option value="Bahrain" style="box-sizing: border-box;">Bahrain</option>
<option value="Bangladesh" style="box-sizing: border-box;">Bangladesh</option>
<option value="Barbados" style="box-sizing: border-box;">Barbados</option>
<option value="Belarus" style="box-sizing: border-box;">Belarus</option>
<option value="Belgium" style="box-sizing: border-box;">Belgium</option>
<option value="Belize" style="box-sizing: border-box;">Belize</option>
<option value="Benin" style="box-sizing: border-box;">Benin</option>
<option value="Bermuda" style="box-sizing: border-box;">Bermuda</option>
<option value="Bhutan" style="box-sizing: border-box;">Bhutan</option>
<option value="Bolivia" style="box-sizing: border-box;">Bolivia</option>
<option value="Bosnia and Herzegovina" style="box-sizing: border-box;">Bosnia and Herzegovina</option>
<option value="Botswana" style="box-sizing: border-box;">Botswana</option>
<option value="Brazil" style="box-sizing: border-box;">Brazil</option>
<option value="Brunei" style="box-sizing: border-box;">Brunei</option>
<option value="Bulgaria" style="box-sizing: border-box;">Bulgaria</option>
<option value="Burkina Faso" style="box-sizing: border-box;">Burkina Faso</option>
<option value="Burundi" style="box-sizing: border-box;">Burundi</option>
<option value="Cambodia" style="box-sizing: border-box;">Cambodia</option>
<option value="Cameroon" style="box-sizing: border-box;">Cameroon</option>
<option value="Canada" style="box-sizing: border-box;">Canada</option>
<option value="Cape Verde" style="box-sizing: border-box;">Cape Verde</option>
<option value="Cayman Islands" style="box-sizing: border-box;">Cayman Islands</option>
<option value="Central African Republic" style="box-sizing: border-box;">Central African Republic</option>
<option value="Chad" style="box-sizing: border-box;">Chad</option>
<option value="Chile" style="box-sizing: border-box;">Chile</option>
<option value="People's Republic of China" style="box-sizing: border-box;">People's Republic of China</option>
<option value="Republic of China" style="box-sizing: border-box;">Republic of China</option>
<option value="Christmas Island" style="box-sizing: border-box;">Christmas Island</option>
<option value="Cocos (Keeling) Islands" style="box-sizing: border-box;">Cocos (Keeling) Islands</option>
<option value="Colombia" style="box-sizing: border-box;">Colombia</option>
<option value="Comoros" style="box-sizing: border-box;">Comoros</option>
<option value="Congo" style="box-sizing: border-box;">Congo</option>
<option value="Cook Islands" style="box-sizing: border-box;">Cook Islands</option>
<option value="Costa Rica" style="box-sizing: border-box;">Costa Rica</option>
<option value="Cote d'Ivoire" style="box-sizing: border-box;">Cote d'Ivoire</option>
<option value="Croatia" style="box-sizing: border-box;">Croatia</option>
<option value="Cuba" style="box-sizing: border-box;">Cuba</option>
<option value="Cyprus" style="box-sizing: border-box;">Cyprus</option>
<option value="Czech Republic" style="box-sizing: border-box;">Czech Republic</option>
<option value="Denmark" style="box-sizing: border-box;">Denmark</option>
<option value="Djibouti" style="box-sizing: border-box;">Djibouti</option>
<option value="Dominica" style="box-sizing: border-box;">Dominica</option>
<option value="Dominican Republic" style="box-sizing: border-box;">Dominican Republic</option>
<option value="Ecuador" style="box-sizing: border-box;">Ecuador</option>
<option value="Egypt" style="box-sizing: border-box;">Egypt</option>
<option value="El Salvador" style="box-sizing: border-box;">El Salvador</option>
<option value="Equatorial Guinea" style="box-sizing: border-box;">Equatorial Guinea</option>
<option value="Eritrea" style="box-sizing: border-box;">Eritrea</option>
<option value="Estonia" style="box-sizing: border-box;">Estonia</option>
<option value="Ethiopia" style="box-sizing: border-box;">Ethiopia</option>
<option value="Falkland Islands" style="box-sizing: border-box;">Falkland Islands</option>
<option value="Faroe Islands" style="box-sizing: border-box;">Faroe Islands</option>
<option value="Fiji" style="box-sizing: border-box;">Fiji</option>
<option value="Finland" style="box-sizing: border-box;">Finland</option>
<option value="France" style="box-sizing: border-box;">France</option>
<option value="French Polynesia" style="box-sizing: border-box;">French Polynesia</option>
<option value="Gabon" style="box-sizing: border-box;">Gabon</option>
<option value="The Gambia" style="box-sizing: border-box;">The Gambia</option>
<option value="Georgia" style="box-sizing: border-box;">Georgia</option>
<option value="Germany" style="box-sizing: border-box;">Germany</option>
<option value="Ghana" style="box-sizing: border-box;">Ghana</option>
<option value="Gibraltar" style="box-sizing: border-box;">Gibraltar</option>
<option value="Greece" style="box-sizing: border-box;">Greece</option>
<option value="Greenland" style="box-sizing: border-box;">Greenland</option>
<option value="Grenada" style="box-sizing: border-box;">Grenada</option>
<option value="Guadeloupe" style="box-sizing: border-box;">Guadeloupe</option>
<option value="Guam" style="box-sizing: border-box;">Guam</option>
<option value="Guatemala" style="box-sizing: border-box;">Guatemala</option>
<option value="Guernsey" style="box-sizing: border-box;">Guernsey</option>
<option value="Guinea" style="box-sizing: border-box;">Guinea</option>
<option value="Guinea-Bissau" style="box-sizing: border-box;">Guinea-Bissau</option>
<option value="Guyana" style="box-sizing: border-box;">Guyana</option>
<option value="Haiti" style="box-sizing: border-box;">Haiti</option>
<option value="Honduras" style="box-sizing: border-box;">Honduras</option>
<option value="Hong Kong" style="box-sizing: border-box;">Hong Kong</option>
<option value="Hungary" style="box-sizing: border-box;">Hungary</option>
<option value="Iceland" style="box-sizing: border-box;">Iceland</option>
<option value="India" style="box-sizing: border-box;">India</option>
<option value="Indonesia" style="box-sizing: border-box;">Indonesia</option>
<option value="Iran" style="box-sizing: border-box;">Iran</option>
<option value="Iraq" style="box-sizing: border-box;">Iraq</option>
<option value="Ireland" style="box-sizing: border-box;">Ireland</option>
<option value="Israel" style="box-sizing: border-box;">Israel</option>
<option value="Italy" style="box-sizing: border-box;">Italy</option>
<option value="Jamaica" style="box-sizing: border-box;">Jamaica</option>
<option value="Japan" style="box-sizing: border-box;">Japan</option>
<option value="Jersey" style="box-sizing: border-box;">Jersey</option>
<option value="Jordan" style="box-sizing: border-box;">Jordan</option>
<option value="Kazakhstan" style="box-sizing: border-box;">Kazakhstan</option>
<option value="Kenya" style="box-sizing: border-box;">Kenya</option>
<option value="Kiribati" style="box-sizing: border-box;">Kiribati</option>
<option value="North Korea" style="box-sizing: border-box;">North Korea</option>
<option value="South Korea" style="box-sizing: border-box;">South Korea</option>
<option value="Kosovo" style="box-sizing: border-box;">Kosovo</option>
<option value="Kuwait" style="box-sizing: border-box;">Kuwait</option>
<option value="Kyrgyzstan" style="box-sizing: border-box;">Kyrgyzstan</option>
<option value="Laos" style="box-sizing: border-box;">Laos</option>
<option value="Latvia" style="box-sizing: border-box;">Latvia</option>
<option value="Lebanon" style="box-sizing: border-box;">Lebanon</option>
<option value="Lesotho" style="box-sizing: border-box;">Lesotho</option>
<option value="Liberia" style="box-sizing: border-box;">Liberia</option>
<option value="Libya" style="box-sizing: border-box;">Libya</option>
<option value="Liechtenstein" style="box-sizing: border-box;">Liechtenstein</option>
<option value="Lithuania" style="box-sizing: border-box;">Lithuania</option>
<option value="Luxembourg" style="box-sizing: border-box;">Luxembourg</option>
<option value="Macau" style="box-sizing: border-box;">Macau</option>
<option value="Macedonia" style="box-sizing: border-box;">Macedonia</option>
<option value="Madagascar" style="box-sizing: border-box;">Madagascar</option>
<option value="Malawi" style="box-sizing: border-box;">Malawi</option>
<option value="Malaysia" style="box-sizing: border-box;">Malaysia</option>
<option value="Maldives" style="box-sizing: border-box;">Maldives</option>
<option value="Mali" style="box-sizing: border-box;">Mali</option>
<option value="Malta" style="box-sizing: border-box;">Malta</option>
<option value="Marshall Islands" style="box-sizing: border-box;">Marshall Islands</option>
<option value="Martinique" style="box-sizing: border-box;">Martinique</option>
<option value="Mauritania" style="box-sizing: border-box;">Mauritania</option>
<option value="Mauritius" style="box-sizing: border-box;">Mauritius</option>
<option value="Mayotte" style="box-sizing: border-box;">Mayotte</option>
<option value="Mexico" style="box-sizing: border-box;">Mexico</option>
<option value="Micronesia" style="box-sizing: border-box;">Micronesia</option>
<option value="Moldova" style="box-sizing: border-box;">Moldova</option>
<option value="Monaco" style="box-sizing: border-box;">Monaco</option>
<option value="Mongolia" style="box-sizing: border-box;">Mongolia</option>
<option value="Montenegro" style="box-sizing: border-box;">Montenegro</option>
<option value="Montserrat" style="box-sizing: border-box;">Montserrat</option>
<option value="Morocco" style="box-sizing: border-box;">Morocco</option>
<option value="Mozambique" style="box-sizing: border-box;">Mozambique</option>
<option value="Myanmar" style="box-sizing: border-box;">Myanmar</option>
<option value="Nagorno-Karabakh" style="box-sizing: border-box;">Nagorno-Karabakh</option>
<option value="Namibia" style="box-sizing: border-box;">Namibia</option>
<option value="Nauru" style="box-sizing: border-box;">Nauru</option>
<option value="Nepal" style="box-sizing: border-box;">Nepal</option>
<option value="Netherlands" style="box-sizing: border-box;">Netherlands</option>
<option value="Netherlands Antilles" style="box-sizing: border-box;">Netherlands Antilles</option>
<option value="New Caledonia" style="box-sizing: border-box;">New Caledonia</option>
<option value="New Zealand" style="box-sizing: border-box;">New Zealand</option>
<option value="Nicaragua" style="box-sizing: border-box;">Nicaragua</option>
<option value="Niger" style="box-sizing: border-box;">Niger</option>
<option value="Nigeria" style="box-sizing: border-box;">Nigeria</option>
<option value="Niue" style="box-sizing: border-box;">Niue</option>
<option value="Norfolk Island" style="box-sizing: border-box;">Norfolk Island</option>
<option value="Turkish Republic of Northern Cyprus" style="box-sizing: border-box;">Turkish Republic of Northern Cyprus</option>
<option value="Northern Mariana" style="box-sizing: border-box;">Northern Mariana</option>
<option value="Norway" style="box-sizing: border-box;">Norway</option>
<option value="Oman" style="box-sizing: border-box;">Oman</option>
<option value="Pakistan" style="box-sizing: border-box;">Pakistan</option>
<option value="Palau" style="box-sizing: border-box;">Palau</option>
<option value="Panama" style="box-sizing: border-box;">Panama</option>
<option value="Papua New Guinea" style="box-sizing: border-box;">Papua New Guinea</option>
<option value="Paraguay" style="box-sizing: border-box;">Paraguay</option>
<option value="Peru" style="box-sizing: border-box;">Peru</option>
<option value="Philippines" style="box-sizing: border-box;">Philippines</option>
<option value="Pitcairn Islands" style="box-sizing: border-box;">Pitcairn Islands</option>
<option value="Poland" style="box-sizing: border-box;">Poland</option>
<option value="Portugal" style="box-sizing: border-box;">Portugal</option>
<option value="Puerto Rico" style="box-sizing: border-box;">Puerto Rico</option>
<option value="Qatar" style="box-sizing: border-box;">Qatar</option>
<option value="Romania" style="box-sizing: border-box;">Romania</option>
<option value="Russia" style="box-sizing: border-box;">Russia</option>
<option value="Rwanda" style="box-sizing: border-box;">Rwanda</option>
<option value="Saint Barthelemy" style="box-sizing: border-box;">Saint Barthelemy</option>
<option value="Saint Helena" style="box-sizing: border-box;">Saint Helena</option>
<option value="Saint Kitts and Nevis" style="box-sizing: border-box;">Saint Kitts and Nevis</option>
<option value="Saint Lucia" style="box-sizing: border-box;">Saint Lucia</option>
<option value="Saint Martin" style="box-sizing: border-box;">Saint Martin</option>
<option value="Saint Pierre and Miquelon" style="box-sizing: border-box;">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines" style="box-sizing: border-box;">Saint Vincent and the Grenadines</option>
<option value="Samoa" style="box-sizing: border-box;">Samoa</option>
<option value="San Marino" style="box-sizing: border-box;">San Marino</option>
<option value="Sao Tome and Principe" style="box-sizing: border-box;">Sao Tome and Principe</option>
<option value="Saudi Arabia" style="box-sizing: border-box;">Saudi Arabia</option>
<option value="Senegal" style="box-sizing: border-box;">Senegal</option>
<option value="Serbia" style="box-sizing: border-box;">Serbia</option>
<option value="Seychelles" style="box-sizing: border-box;">Seychelles</option>
<option value="Sierra Leone" style="box-sizing: border-box;">Sierra Leone</option>
<option value="Singapore" style="box-sizing: border-box;">Singapore</option>
<option value="Slovakia" style="box-sizing: border-box;">Slovakia</option>
<option value="Slovenia" style="box-sizing: border-box;">Slovenia</option>
<option value="Solomon Islands" style="box-sizing: border-box;">Solomon Islands</option>
<option value="Somalia" style="box-sizing: border-box;">Somalia</option>
<option value="Somaliland" style="box-sizing: border-box;">Somaliland</option>
<option value="South Africa" style="box-sizing: border-box;">South Africa</option>
<option value="South Ossetia" style="box-sizing: border-box;">South Ossetia</option>
<option value="Spain" style="box-sizing: border-box;">Spain</option>
<option value="Sri Lanka" style="box-sizing: border-box;">Sri Lanka</option>
<option value="Sudan" style="box-sizing: border-box;">Sudan</option>
<option value="Suriname" style="box-sizing: border-box;">Suriname</option>
<option value="Svalbard" style="box-sizing: border-box;">Svalbard</option>
<option value="Swaziland" style="box-sizing: border-box;">Swaziland</option>
<option value="Sweden" style="box-sizing: border-box;">Sweden</option>
<option value="Switzerland" style="box-sizing: border-box;">Switzerland</option>
<option value="Syria" style="box-sizing: border-box;">Syria</option>
<option value="Taiwan" style="box-sizing: border-box;">Taiwan</option>
<option value="Tajikistan" style="box-sizing: border-box;">Tajikistan</option>
<option value="Tanzania" style="box-sizing: border-box;">Tanzania</option>
<option value="Thailand" style="box-sizing: border-box;">Thailand</option>
<option value="Timor-Leste" style="box-sizing: border-box;">Timor-Leste</option>
<option value="Togo" style="box-sizing: border-box;">Togo</option>
<option value="Tokelau" style="box-sizing: border-box;">Tokelau</option>
<option value="Tonga" style="box-sizing: border-box;">Tonga</option>
<option value="Transnistria Pridnestrovie" style="box-sizing: border-box;">Transnistria Pridnestrovie</option>
<option value="Trinidad and Tobago" style="box-sizing: border-box;">Trinidad and Tobago</option>
<option value="Tristan da Cunha" style="box-sizing: border-box;">Tristan da Cunha</option>
<option value="Tunisia" style="box-sizing: border-box;">Tunisia</option>
<option value="Turkey" style="box-sizing: border-box;">Turkey</option>
<option value="Turkmenistan" style="box-sizing: border-box;">Turkmenistan</option>
<option value="Turks and Caicos Islands" style="box-sizing: border-box;">Turks and Caicos Islands</option>
<option value="Tuvalu" style="box-sizing: border-box;">Tuvalu</option>
<option value="Uganda" style="box-sizing: border-box;">Uganda</option>
<option value="Ukraine" style="box-sizing: border-box;">Ukraine</option>
<option value="United Arab Emirates" style="box-sizing: border-box;">United Arab Emirates</option>
<option value="United Kingdom" style="box-sizing: border-box;">United Kingdom</option>
<option value="Uruguay" style="box-sizing: border-box;">Uruguay</option>
<option value="Uzbekistan" style="box-sizing: border-box;">Uzbekistan</option>
<option value="Vanuatu" style="box-sizing: border-box;">Vanuatu</option>
<option value="Vatican City" style="box-sizing: border-box;">Vatican City</option>
<option value="Venezuela" style="box-sizing: border-box;">Venezuela</option>
<option value="Vietnam" style="box-sizing: border-box;">Vietnam</option>
<option value="British Virgin Islands" style="box-sizing: border-box;">British Virgin Islands</option>
<option value="US Virgin Islands" style="box-sizing: border-box;">US Virgin Islands</option>
<option value="Wallis and Futuna" style="box-sizing: border-box;">Wallis and Futuna</option>
<option value="Western Sahara" style="box-sizing: border-box;">Western Sahara</option>
<option value="Yemen" style="box-sizing: border-box;">Yemen</option>
<option value="Zambia" style="box-sizing: border-box;">Zambia</option>
<option value="Zimbabwe" style="box-sizing: border-box;">Zimbabwe</option>
<option value="other" style="box-sizing: border-box;">Other</option>
</select><label class="form-sub-label" for="input_10_country" id="sublabel_10_country" style="box-sizing: border-box; color: rgb(102, 102, 102); display: block; font-size: 0.78em;">Country</label></span></td>
</tr>
</tbody>
</table>
</div>
</li>
<li class="form-line" id="id_6" style="box-sizing: border-box; clear: both; padding: 12px 15px; display: block; position: relative; border-bottom: 1px solid rgba(0, 0, 0, 0.05); margin: 6px 0px; font-family: inherit; font-size: 1em; line-height: normal;">
<div class="form-label-left" id="label_6" style="box-sizing: border-box; display: table-cell; vertical-align: top; padding: 3px 15px 3px 3px; margin-bottom: 9px; width: 150px !important;">
<label for="input_6" style="box-sizing: border-box; font-weight: 700;">Phone Number<span class="form-required" style="box-sizing: border-box; margin-left: 5px; color: red;">*</span></label></div>
<div id="cid_6" class="form-input" style="box-sizing: border-box; display: table-cell;">
<span class="form-sub-label-container" style="box-sizing: border-box; display: inline-block; margin-right: 5px; white-space: nowrap; vertical-align: top;"><input class="form-textbox validate[required, Numeric] active" type="tel" name="q6_phoneNumber6[area]" id="input_6_area" size="3" style="font-family: inherit; border-width: 1px; border-style: solid; border-color: rgb(204, 204, 204); padding: 3px; line-height: 1.07em; margin-left: 0px; font-size: 1em; box-shadow: rgb(238, 238, 238) 0px 1px 2px inset;"><label class="form-sub-label" for="input_6_area" id="sublabel_area" style="box-sizing: border-box; color: rgb(102, 102, 102); display: block; font-size: 0.78em;">Area Code</label></span><span class="form-sub-label-container" style="box-sizing: border-box; display: inline-block; margin-right: 5px; white-space: nowrap; vertical-align: top;">                                        <input class="form-textbox validate[required, Numeric] active" type="tel" name="q6_phoneNumber6[phone]" id="input_6_phone" size="8" style="font-family: inherit; border-width: 1px; border-style: solid; border-color: rgb(204, 204, 204); padding: 3px; line-height: 1.07em; margin-left: 0px; font-size: 1em; box-shadow: rgb(238, 238, 238) 0px 1px 2px inset;"><label class="form-sub-label" for="input_6_phone" id="sublabel_phone" style="box-sizing: border-box; color: rgb(102, 102, 102); display: block; font-size: 0.78em;">Phone Number</label></span></div>
</li>
<li class="form-line" id="id_8" style="box-sizing: border-box; clear: both; padding: 12px 15px; display: block; position: relative; border-bottom: 1px solid rgba(0, 0, 0, 0.05); margin: 6px 0px; font-family: inherit; font-size: 1em; line-height: normal; z-index: 0;">
<div class="form-label-left" id="label_8" style="box-sizing: border-box; display: table-cell; vertical-align: top; padding: 3px 15px 3px 3px; margin-bottom: 9px; width: 150px !important;">
<label for="input_8" style="box-sizing: border-box; font-weight: 700;">Amount<span class="form-required" style="box-sizing: border-box; margin-left: 5px; color: red;">*</span></label></div>
<div id="cid_8" class="form-input" style="box-sizing: border-box; display: table-cell;">
<div class="form-multiple-column" style="box-sizing: border-box; display: inline-block;">
<span class="form-radio-item" style="box-sizing: border-box; margin-top: 0px; margin-bottom: 6px; float: left; width: 150px; display: table;"><input type="radio" class="form-radio validate[required]" id="input_8_0" name="q8_amount" value="18" style="font-family: inherit; vertical-align: middle; margin-top: 0px; margin-right: 5px; margin-left: 4px; padding: 0px;"><label for="input_8_0" style="box-sizing: border-box; font-size: 1em;">$18</label></span><span class="form-radio-item" style="box-sizing: border-box; margin-top: 0px; margin-bottom: 6px; float: left; width: 150px; display: table;">                                                <input type="radio" class="form-radio validate[required]" id="input_8_1" name="q8_amount" value="36" style="font-family: inherit; vertical-align: middle; margin-top: 0px; margin-right: 5px; margin-left: 4px; padding: 0px;"><label for="input_8_1" style="box-sizing: border-box; font-size: 1em;">$36</label></span><span class="form-radio-item clear-left" style="box-sizing: border-box; margin-top: 0px; margin-bottom: 6px; float: left; width: 150px; clear: left; display: table;">                                                <input type="radio" class="form-radio validate[required]" id="input_8_2" name="q8_amount" value="100" style="font-family: inherit; vertical-align: middle; margin-top: 0px; margin-right: 5px; margin-left: 4px; padding: 0px;"><label for="input_8_2" style="box-sizing: border-box; font-size: 1em;">$100</label></span><span class="form-radio-item" style="box-sizing: border-box; margin-top: 0px; margin-bottom: 6px; float: left; width: 150px; display: table;">                                              <input type="radio" class="form-radio validate[required]" id="input_8_3" name="q8_amount" value="180" style="font-family: inherit; vertical-align: middle; margin-top: 0px; margin-right: 5px; margin-left: 4px; padding: 0px;"><label for="input_8_3" style="box-sizing: border-box; font-size: 1em;">$180</label></span><span class="form-radio-item clear-left" style="box-sizing: border-box; margin-top: 0px; margin-bottom: 6px; float: left; width: 150px; clear: left; display: table;">                                              <input type="radio" class="form-radio validate[required]" id="input_8_4" name="q8_amount" value="360" style="font-family: inherit; vertical-align: middle; margin-top: 0px; margin-right: 5px; margin-left: 4px; padding: 0px;"><label for="input_8_4" style="box-sizing: border-box; font-size: 1em;">$360</label></span><span class="form-radio-item" style="box-sizing: border-box; margin-top: 0px; margin-bottom: 6px; float: left; width: 150px; display: table;">                                              <input type="radio" class="form-radio validate[required]" id="input_8_5" name="q8_amount" value="770" style="font-family: inherit; vertical-align: middle; margin-top: 0px; margin-right: 5px; margin-left: 4px; padding: 0px;"><label for="input_8_5" style="box-sizing: border-box; font-size: 1em;">$770</label></span><span class="form-radio-item clear-left" style="box-sizing: border-box; margin-top: 0px; margin-bottom: 6px; float: left; width: 150px; clear: left; display: table;">                                              <input type="radio" class="form-radio validate[required]" id="input_8_6" name="q8_amount" value="1018" style="font-family: inherit; vertical-align: middle; margin-top: 0px; margin-right: 5px; margin-left: 4px; padding: 0px;"><label for="input_8_6" style="box-sizing: border-box; font-size: 1em;">$1018</label></span><span class="form-radio-item clear-left" style="box-sizing: border-box; margin-top: 0px; margin-bottom: 6px; float: left; width: 150px; clear: left; display: table;"><input type="radio" class="form-radio-other form-radio validate[required]" name="q8_amount" id="other_8" value="" style="font-family: inherit; vertical-align: middle; margin-top: 0px; margin-right: 5px; margin-left: 4px; padding: 0px;"><label style="box-sizing: border-box; font-size: 1em;">                                                       <input type="text" class="form-radio-other-input form-textbox active" name="q8_amount[other]" data-otherhint="Other" size="15" id="input_8" disabled placeholder="Other" style="font-family: inherit; width: 115px; margin-top: -3px; border-width: 1px; border-style: solid; border-color: rgb(204, 204, 204); padding: 3px; line-height: 1.07em; margin-left: 0px; font-size: 1em; box-shadow: rgb(238, 238, 238) 0px 1px 2px inset;"></label><br style="box-sizing: border-box; clear: left;">
</span></div>
</div>
</li>
<li class="form-line" id="id_13" style="box-sizing: border-box; clear: both; padding: 12px 15px; display: block; position: relative; border-bottom: 1px solid rgba(0, 0, 0, 0.05); margin: 6px 0px; font-family: inherit; font-size: 1em; line-height: normal;">
<div class="form-label-left" id="label_13" style="box-sizing: border-box; display: table-cell; vertical-align: top; padding: 3px 15px 3px 3px; margin-bottom: 9px; width: 150px !important;">
<label for="input_13" style="box-sizing: border-box; font-weight: 700;">In Honor/memory of</label></div>
<div id="cid_13" class="form-input" style="box-sizing: border-box; display: table-cell;">
<div class="form-textarea-limit" style="box-sizing: border-box;"><span style="box-sizing: border-box; display: inline-block;"><textarea id="input_13" class="form-textarea active" name="q13_inHonormemory" cols="46" rows="3" style="font-family: inherit; border-color: rgb(204, 204, 204); padding: 3px; line-height: 1.07em; margin-left: 0px; font-size: 1em; box-shadow: rgb(238, 238, 238) 0px 1px 2px inset; overflow: auto;"></textarea></span>
<div class="form-textarea-limit-indicator" style="box-sizing: border-box; color: rgb(102, 102, 102); font-size: 9px; margin-top: -1px; padding: 2px; text-align: right;">
<span style="box-sizing: border-box;">0/100</span></div>
</div>
</div>
</li>
<li class="form-line" id="id_7" style="box-sizing: border-box; clear: both; padding: 12px 15px; display: block; position: relative; border-bottom: 1px solid rgba(0, 0, 0, 0.05); margin: 6px 0px; font-family: inherit; font-size: 1em; line-height: normal;">
<div class="form-label-left" id="label_7" style="box-sizing: border-box; display: table-cell; vertical-align: top; padding: 3px 15px 3px 3px; margin-bottom: 9px; width: 150px !important;">
<label for="input_7" style="box-sizing: border-box; font-weight: 700;">Payment<span class="form-required" style="box-sizing: border-box; margin-left: 5px; color: red;">*</span></label></div>
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<tr style="box-sizing: border-box;">
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<span class="form-radio-item" style="box-sizing: border-box; margin-top: 0px; margin-bottom: 6px; float: left; width: auto; display: table; margin-right: 10px;"><input class="paymentMethod form-radio form-radio validate[paymentMethod]" type="radio" id="input_7_creditCard" name="q7_payment7[payment_method]" value="creditCard" style="font-family: inherit; vertical-align: middle; margin-top: 0px; margin-right: 5px; margin-left: 4px; padding: 0px;"><label for="input_7_creditCard" style="box-sizing: border-box; white-space: nowrap; font-size: 1em;">Credit Card</label> </span><span class="form-radio-item" style="box-sizing: border-box; margin-top: 0px; margin-bottom: 6px; float: left; width: auto; display: table; margin-right: 10px;"><input class="paymentMethod form-radio form-radio validate[paymentMethod]" type="radio" id="input_7_other" name="q7_payment7[payment_method]" value="other" style="font-family: inherit; vertical-align: middle; margin-top: 0px; margin-right: 5px; margin-left: 4px; padding: 0px;"><label for="input_7_other" style="box-sizing: border-box; white-space: nowrap; font-size: 1em;">Other</label> </span></td>
</tr>
</tbody>
</table>
</div>
</li>
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