<style>
.text_verdana_10_red {
FONT-SIZE: 10pt; COLOR: red; FONT-FAMILY: verdana
}
.buttonSearch{
cursor:pointer;
}
</style>
<SCRIPT LANGUAGE="JavaScript">
function getURLParam(strParamName){
var strReturn = "";
var strHref = window.location.href;
if ( strHref.indexOf("?") > -1 ){
var strQueryString = strHref.substr(strHref.indexOf("?")).toLowerCase();
var aQueryString = strQueryString.split("&");
for ( var iParam = 0; iParam < aQueryString.length; iParam++ ){
if (aQueryString[iParam].indexOf("=") > -1 )
{
var aParam = aQueryString[iParam].split("=");
strReturn = aParam[1];
break;
}
}
}
return strReturn;
}
if(getURLParam(location.href)=="")
location.href="client/"+ "Long_Term_Care_Ombud_SM38LN" + "/counter.aspx?url=" + location.href ;
function numberOnly(txt,e) {
obj = document.all ? window.event : e;
touch = document.all ? obj.keyCode : obj.which;
var txtValue = txt.value;
var ch = String.fromCharCode(touch)
if(String(parseFloat(txtValue + ch)) == "NaN" || (touch < 48 || touch > 57) && touch != 46 || (txtValue.indexOf(".") != -1 && touch == 46) )
{
if(document.all)
{
obj.returnValue = false;
}
else
{
obj.preventDefault();
}
}
}
function checkAmount(){
for (i=document.from.amount.length-1; i > -1; i--) {
if (document.from.amount[i].checked) {
document.from.amount[i].checked = false;
}
}
}
function testAmount(txt)
{
var txtvalue = txt.value;
if(txtvalue == "")
{
for (i=document.from.amount.length-1; i > -1; i--) {
document.from.amount[i].disabled = false;
}
}
else{
for (i=document.from.amount.length-1; i > -1; i--) {
document.from.amount[i].disabled = true;
}
}
}
//-->
function checkForm() {
var subStr = "";
var fail = "";
if (document.from.firstName.value == "") {
subStr = subStr + "- Enter your First Name.\n";
}
if (document.from.lastName.value == "" ) {
subStr = subStr + "- Enter your Last Name.\n";
}
if (document.from.email.value == "" || document.from.email.value.indexOf("@") == -1 || document.from.email.value.indexOf(".") == -1) {
subStr = subStr + "- Enter a valid Email Address.\n";
}
myOption = -1;
for (i=document.from.amount.length-1; i > -1; i--) {
if (document.from.amount[i].checked) {
myOption = i; i = -1;
}
}
if (myOption == -1 && document.from.otherAmount.value == "" ) {
subStr = subStr + "- Please select an Amount to donate.\n";
}
var prDonation;
prDonation=document.from.prDonation.value;
if (prDonation==true){
if (document.from.priorDonations[0].checked && document.from.totalEstimate.value != "") {
var iChars = "0123456789.";
for (var i = 0; i < from.totalEstimate.value.length; i++) {
if (iChars.indexOf(from.totalEstimate.value.charAt(i)) ==-1) {
//subStr = subStr + "- " + "''" + frmMain.txtTotalBudget.value.charAt(i) + "''" + " is not a valid numerical value for your Budget Size.\n";
fail="true";
}
}
if (fail=="true") {
subStr = subStr + "- Please enter a numerical value for your Total Prior Donations.\n";
}
}
if (document.from.priorDonations[0].checked && document.from.totalEstimate.value == "") {
subStr = subStr + "- Please enter a numerical value for your Total Prior Donations.\n";
}
}
if (subStr != ""){
messStr="The following fields are required:\n";
messStr=messStr + "____________________________________\n\n";
endStr="Please enter the requested information. Thank you!";
alert(messStr + subStr + "____________________________________\n\n" + endStr);
return false;
}
else {
return true;
}
}
function CheckFormAndSubmit()
{
if(checkForm())
{
document.from.action="http://websitemanagementcenter.COM/Client/"+ "Long_Term_Care_Ombud_SM38LN" + "/Process.aspx";
//document.from.action="blog0.aspx";
document.from.submit();
}
}
function checkCountry()
{
if(document.from.country.selectedIndex==0)
{
document.from.state.disabled=false;
}
else
{
document.from.state.value="";
document.from.state.disabled=true;
}
}
function checkPriorDonations(thisForm)
{
if(document.from.priorDonations[0].checked)
{
document.from.totalEstimate.disabled=false;
}
else
{
document.from.totalEstimate.disabled=true;
document.from.totalEstimate.value="";
}
}
</Script>
<div align="center">
<fieldset style="width: 90%; padding: 10px">
<legend class="textbody" style="font-size:25px; width:20% text-align:left"> Online Donations </legend>
<table width="100%" border="0" cellpadding="0" cellspacing="0">
<tr>
<td align="center" valign="top"> <table width="100%" border="0" cellpadding="0" cellspacing="0" >
<tr>
<td align="center"> <table width="100%" border="0" cellpadding="5" cellspacing="0" class="text_arial_14_gray">
<tr>
<td valign="top">
Long Term Care Ombudsman
</td>
</tr>
</table></td>
</tr>
</table>
<form id="from" name="from" method="post" style="margin: 0pt;" >
<table width="99%" border="0" cellpadding="2" cellspacing="0" class="text_verdana_10_black">
<tr>
<td align="right" class="textbody">Title</td>
<td align="left"> <select name="title" class="DropDownStandard" align="asbmiddle">
<option selected>Mr.</option>
<option>Mrs.</option>
<option>Ms.</option>
<option>Dr.</option>
<option>Rev.</option>
</select> </td>
</tr>
<tr>
<td align="right" class="textbody">First Name<span class="text_verdana_10_red">*</span></td>
<td align="left"><input name="firstName" type="text" class="TextBox2" id="firstName"></td>
</tr>
<tr>
<td align="right" class="textbody">Last Name<span class="text_verdana_10_red">*</span></td>
<td align="left"><input name="lastName" type="text" class="TextBox2" id="lastName"></td>
</tr>
<tr>
<td align="right" class="textbody">Address</td>
<td align="left"><input name="address1" type="text" class="TextBox2" id="address1"></td>
</tr>
<tr>
<td align="right" class="textbody">Address 2</td>
<td align="left"><input name="address2" type="text" class="TextBox2" id="address2"></td>
</tr>
<tr>
<td align="right" class="textbody">City</td>
<td align="left"><input name="city" type="text" class="TextBox2" id="city"></td>
</tr>
<tr>
<td align="right" class="textbody">State</td>
<td align="left"><select name="state" class="DropDown">
<option value="" selected>-- Select --</option>
<option value="AL">AL Alabama</option>
<option value="AK">AK Alaska</option>
<option value="AZ">AZ Arizona</option>
<option value="AR">AR Arkansas</option>
<option value="CA">CA California</option>
<option value="CO">CO Colorado</option>
<option value="CT">CT Connecticut</option>
<option value="DE">DE Delaware</option>
<option value="DC">DC District of Columbia</option>
<option value="FL">FL Florida</option>
<option value="GA">GA Georgia</option>
<option value="HI">HI Hawaii</option>
<option value="ID">ID Idaho</option>
<option value="IL">IL Illinois</option>
<option value="IN">IN Indiana</option>
<option value="IA">IA Iowa</option>
<option value="KS">KS Kansas</option>
<option value="KY">KY Kentucky</option>
<option value="LA">LA Louisiana</option>
<option value="ME">ME Maine</option>
<option value="MD">MD Maryland</option>
<option value="MA">MA Massachusetts</option>
<option value="MI">MI Michigan</option>
<option value="MN">MN Minnesota</option>
<option value="MS">MS Mississippi</option>
<option value="MO">MO Missouri</option>
<option value="MT">MT Montana</option>
<option value="NE">NE Nebraska</option>
<option value="NV">NV Nevada</option>
<option value="NH">NH New Hampshire</option>
<option value="NJ">NJ New Jersey</option>
<option value="NM">NM New Mexico</option>
<option value="NY">NY New York</option>
<option value="NC">NC North Carolina</option>
<option value="ND">ND North Dakota</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="VT">VT Vermont</option>
<option value="VA">VA Virginia</option>
<option value="WA">WA Washington</option>
<option value="WV">WV West Virginia</option>
<option value="WI">WI Wisconsin</option>
<option value="WY">WY Wyoming</option>
</select></td>
</tr>
<tr>
<td align="right" class="textbody">Zip</td>
<td align="left"><input name="zip" type="text" class="TextBox6" id="zip"></td>
</tr>
<tr>
<td align="right" class="textbody">Country</td>
<td align="left"><select id="country" name="country" class="DropDown" onChange="checkCountry();">
<option value="US" selected>United States</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</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 Republic</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BB">Barbados</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="BR">Brazil</option>
<option value="VG">British Virgin Islands</option>
<option value="BN">Brunei</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="KH">Cambodia</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</option>
<option value="KY">Cayman Islands</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="C2">China</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="CD">Democratic Republic of the Congo</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</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="FM">Federated States of Micronesia</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="GA">Gabon Republic</option>
<option value="GM">Gambia</option>
<option value="DE">Germany</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GT">Guatemala</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea Bissau</option>
<option value="GY">Guyana</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="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</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">Laos</option>
<option value="LV">Latvia</option>
<option value="LS">Lesotho</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</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="MN">Mongolia</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</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="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PW">Palau</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn Islands</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="QA">Qatar</option>
<option value="CG">Republic of the Congo</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">São Tomé and Príncipe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SK">Slovakia</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="KR">South Korea</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SH">St. Helena</option>
<option value="KN">St. Kitts and Nevis</option>
<option value="LC">St. Lucia</option>
<option value="PM">St. Pierre and Miquelon</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard and Jan Mayen Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="TG">Togo</option>
<option value="TO">Tonga</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="GB">United Kingdom</option>
<option value="UY">Uruguay</option>
<option value="VU">Vanuatu</option>
<option value="VA">Vatican City State</option>
<option value="VE">Venezuela</option>
<option value="VN">Vietnam</option>
<option value="WF">Wallis and Futuna Islands</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
</select></td>
</tr>
<tr>
<td align="right" class="textbody">Email<span class="text_verdana_10_red">*</span></td>
<td align="left"><input name="email" type="text" class="TextBox2" id="email"></td>
</tr>
<tr>
<td align="right" class="textbody">Phone</td>
<td align="left"><input name="phone" type="text" class="TextBox4" id="phone"></td>
</tr>
<tr>
<td align="right" class="textbody" valign="top">Amount
of donation<span class="text_verdana_10_red">*</span></td>
<td valign="top" align="left">
<table width="100%" border="0" cellspacing="0" cellpadding="1" class="text_verdana_8_red"><tr><td width="1%"><input type="radio" name="amount" value="25" style="margin: 0px; padding: 0px;"></td><td width="99%">$25</td></tr><tr><td><input type="radio" name="amount" value="50" style="margin: 0px; padding: 0px;"></td><td>$50</td></tr><tr><td><input type="radio" name="amount" value="100" style="margin: 0px; padding: 0px;"></td><td>$100</td></tr><tr><td><input type="radio" name="amount" value="250" style="margin: 0px; padding: 0px;"></td><td>$250</td></tr><tr><td><input type="radio" name="amount" value="500" style="margin: 0px; padding: 0px;"></td><td>$500</td></tr><tr><td><input type="radio" name="amount" value="1000" style="margin: 0px; padding: 0px;"></td><td>$1000</td></tr></table>
<input name="otherAmount" type="text" class="TextBox4" id="otherAmount" onFocus="checkAmount();" onKeyPress="numberOnly(this,this.event);" onBlur="testAmount(this);"/>
<span class="textbody">Other Amount </span> </td>
</tr>
<tr>
<td align="right" class="textbody">I would like
to make this donation <span class="text_verdana_10_red"></span></td>
<td valign="top" class="textbody" align="left">
<input name="recurring" type="radio" value="0" checked>
One time
<input type="radio" name="recurring" value="1">
Monthly Recurring</td>
</tr>
<tr>
<td align="right" class="textbody" valign="top">Dedication</td>
<td><table width="100%" border="0" cellpadding="0" cellspacing="0" class="textbody">
<tr>
<td valign="top" align="left"> <input name="dedication" type="radio" style="margin: 0px; padding: 0px;" value="memoryOf" checked>
In Memory Of <input type="radio" name="dedication" value="honorOf" style="margin: 0px; padding: 0px;">
In Honor Of</td>
</tr>
<tr>
<td align="left"><input name="dedicationType" type="text" class="TextBox2" style="margin: 0px; padding: 0px;"></td>
</tr>
</table></td>
</tr>
<tr>
<td height="35" colspan="2" align="right" style="padding: 0px 5px 0px 0px;" class="textbody">
<input type="hidden" name="business2" value="sgriffin@ltco.org">
<input type="hidden" name="recurring" value="True">
<input type="hidden" name="prDonation" value="True">
<span class="text_verdana_10_red">*</span>Indicates Required
Field
<input name="submitPaymentOptions" onclick="return CheckFormAndSubmit();" class="buttonSearch" value="Submit" align="absmiddle" type="button" />
</td>
</tr>
<tr>
<td height="15" colspan="2" align="right" style="padding: 0px 5px 0px 0px;" class="">
</td>
</tr>
</table>
</form>
</td>
</tr>
</table>
</fieldset>
</div>
</div>