<p>How would you like to donate</p><!-- [et_pb_line_break_holder] --> <br><!-- [et_pb_line_break_holder] --><br><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <div class="donatecontent"><!-- [et_pb_line_break_holder] --> <input type="radio" name="gift" value="onetime" required=""><label>One Time Gift</label><!-- [et_pb_line_break_holder] --> <input type="radio" name="gift" value="monthly"><label>Monthly Gift</label><!-- [et_pb_line_break_holder] --> <input type="radio" name="gift" value="memorial"><label>Honor/Memorial Gift</label><!-- [et_pb_line_break_holder] --> <label id="condition" style="visibility:hidden;font-size:.7em;">*Go to step number 3</label><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div>

<p>I want to help</p><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <input type="radio" name="amount" value="31" required=""><img src="https://kdcky.com/wp-content/uploads/2018/07/31.png" height="10%"><!-- [et_pb_line_break_holder] --> <input type="radio" name="amount" value="50"><img src="https://kdcky.com/wp-content/uploads/2018/07/50-1.png" height="60%"><!-- [et_pb_line_break_holder] -->

<input type="radio" name="amount" value="100"><img src="https://kdcky.com/wp-content/uploads/2018/07/100-1.png" height="60%"><!-- [et_pb_line_break_holder] --> <input type="radio" name="amount" value="500"><img src="https://kdcky.com/wp-content/uploads/2018/07/500-1.png" height="60%"><!-- [et_pb_line_break_holder] --> <input type="radio" name="amount" value="1000"><img src="https://kdcky.com/wp-content/uploads/2018/07/1000-1.png" height="60%"><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] -->

 <p>This is my biodata</p> <!-- [et_pb_line_break_holder] --><p>  </p><!-- [et_pb_line_break_holder] -->  </div><!-- [et_pb_line_break_holder] --> <div class="donatecontent"><!-- [et_pb_line_break_holder] --> <table border="0" style="width:80%;"><!-- [et_pb_line_break_holder] --> <tbody><tr><!-- [et_pb_line_break_holder] --> <td class="label" id="labelForm"><p style="margin:0;color:#7a7a7a;">Full Name *</p></td><!-- [et_pb_line_break_holder] --> <td><input type="text" id="fullname" name="fullname" value="" pattern="^[A-Za-z ]+$" required=""></td><!-- [et_pb_line_break_holder] --> <td style="width:5%"> </td><!-- [et_pb_line_break_holder] --> <td class="label" id="labelForm"><p style="margin:0;color:#7a7a7a;">ZIP *</p></td><!-- [et_pb_line_break_holder] --> <td><input type="text" id="zip" name="zip" value="" pattern="\d{5}-?(\d{4})?" required=""></td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td class="label" id="labelForm"><p style="margin:0;color:#7a7a7a;">Address *</p></td><!-- [et_pb_line_break_holder] --> <td><input type="text" id="address" name="address" value="" pattern="^[A-Za-z ]+$" required=""></td><!-- [et_pb_line_break_holder] --> <td style="width:5%"> </td><!-- [et_pb_line_break_holder] --> <td class="label" id="labelForm"><p style="margin:0;color:#7a7a7a;">Country *</p></td><!-- [et_pb_line_break_holder] --> <td><select name="country" id="country" style="width:100%"><!-- [et_pb_line_break_holder] --> <option value="">Country</option><!-- [et_pb_line_break_holder] --> <option value="Afganistan">Afghanistan</option><!-- [et_pb_line_break_holder] --> <option value="Albania">Albania</option><!-- [et_pb_line_break_holder] --> <option value="Algeria">Algeria</option><!-- [et_pb_line_break_holder] --> <option value="American Samoa">American Samoa</option><!-- [et_pb_line_break_holder] --> <option value="Andorra">Andorra</option><!-- [et_pb_line_break_holder] --> <option value="Angola">Angola</option><!-- [et_pb_line_break_holder] --> <option value="Anguilla">Anguilla</option><!-- [et_pb_line_break_holder] --> <option value="Antigua & Barbuda">Antigua & Barbuda</option><!-- [et_pb_line_break_holder] --> <option value="Argentina">Argentina</option><!-- [et_pb_line_break_holder] --> <option value="Armenia">Armenia</option><!-- [et_pb_line_break_holder] --> <option value="Aruba">Aruba</option><!-- [et_pb_line_break_holder] --> <option value="Australia">Australia</option><!-- [et_pb_line_break_holder] --> <option value="Austria">Austria</option><!-- [et_pb_line_break_holder] --> <option value="Azerbaijan">Azerbaijan</option><!-- [et_pb_line_break_holder] --> <option value="Bahamas">Bahamas</option><!-- [et_pb_line_break_holder] --> <option value="Bahrain">Bahrain</option><!-- [et_pb_line_break_holder] --> <option value="Bangladesh">Bangladesh</option><!-- [et_pb_line_break_holder] --> <option value="Barbados">Barbados</option><!-- [et_pb_line_break_holder] --> <option value="Belarus">Belarus</option><!-- [et_pb_line_break_holder] --> <option value="Belgium">Belgium</option><!-- [et_pb_line_break_holder] --> <option value="Belize">Belize</option><!-- [et_pb_line_break_holder] --> <option value="Benin">Benin</option><!-- [et_pb_line_break_holder] --> <option value="Bermuda">Bermuda</option><!-- [et_pb_line_break_holder] --> <option value="Bhutan">Bhutan</option><!-- [et_pb_line_break_holder] --> <option value="Bolivia">Bolivia</option><!-- [et_pb_line_break_holder] --> <option value="Bonaire">Bonaire</option><!-- [et_pb_line_break_holder] --> <option value="Bosnia & Herzegovina">Bosnia & Herzegovina</option><!-- [et_pb_line_break_holder] --> <option value="Botswana">Botswana</option><!-- [et_pb_line_break_holder] --> <option value="Brazil">Brazil</option><!-- [et_pb_line_break_holder] --> <option value="British Indian Ocean Ter">British Indian Ocean Ter</option><!-- [et_pb_line_break_holder] --> <option value="Brunei">Brunei</option><!-- [et_pb_line_break_holder] --> <option value="Bulgaria">Bulgaria</option><!-- [et_pb_line_break_holder] --> <option value="Burkina Faso">Burkina Faso</option><!-- [et_pb_line_break_holder] --> <option value="Burundi">Burundi</option><!-- [et_pb_line_break_holder] --> <option value="Cambodia">Cambodia</option><!-- [et_pb_line_break_holder] --> <option value="Cameroon">Cameroon</option><!-- [et_pb_line_break_holder] --> <option value="Canada">Canada</option><!-- [et_pb_line_break_holder] --> <option value="Canary Islands">Canary Islands</option><!-- [et_pb_line_break_holder] --> <option value="Cape Verde">Cape Verde</option><!-- [et_pb_line_break_holder] --> <option value="Cayman Islands">Cayman Islands</option><!-- [et_pb_line_break_holder] --> <option value="Central African Republic">Central African Republic</option><!-- [et_pb_line_break_holder] --> <option value="Chad">Chad</option><!-- [et_pb_line_break_holder] --> <option value="Channel Islands">Channel Islands</option><!-- [et_pb_line_break_holder] --> <option value="Chile">Chile</option><!-- [et_pb_line_break_holder] --> <option value="China">China</option><!-- [et_pb_line_break_holder] --> <option value="Christmas Island">Christmas Island</option><!-- [et_pb_line_break_holder] --> <option value="Cocos Island">Cocos Island</option><!-- [et_pb_line_break_holder] --> <option value="Colombia">Colombia</option><!-- [et_pb_line_break_holder] --> <option value="Comoros">Comoros</option><!-- [et_pb_line_break_holder] --> <option value="Congo">Congo</option><!-- [et_pb_line_break_holder] --> <option value="Cook Islands">Cook Islands</option><!-- [et_pb_line_break_holder] --> <option value="Costa Rica">Costa Rica</option><!-- [et_pb_line_break_holder] --> <option value="Cote DIvoire">Cote D'Ivoire</option><!-- [et_pb_line_break_holder] --> <option value="Croatia">Croatia</option><!-- [et_pb_line_break_holder] --> <option value="Cuba">Cuba</option><!-- [et_pb_line_break_holder] --> <option value="Curaco">Curacao</option><!-- [et_pb_line_break_holder] --> <option value="Cyprus">Cyprus</option><!-- [et_pb_line_break_holder] --> <option value="Czech Republic">Czech Republic</option><!-- [et_pb_line_break_holder] --> <option value="Denmark">Denmark</option><!-- [et_pb_line_break_holder] --> <option value="Djibouti">Djibouti</option><!-- [et_pb_line_break_holder] --> <option value="Dominica">Dominica</option><!-- [et_pb_line_break_holder] --> <option value="Dominican Republic">Dominican Republic</option><!-- [et_pb_line_break_holder] --> <option value="East Timor">East Timor</option><!-- [et_pb_line_break_holder] --> <option value="Ecuador">Ecuador</option><!-- [et_pb_line_break_holder] --> <option value="Egypt">Egypt</option><!-- [et_pb_line_break_holder] --> <option value="El Salvador">El Salvador</option><!-- [et_pb_line_break_holder] --> <option value="Equatorial Guinea">Equatorial Guinea</option><!-- [et_pb_line_break_holder] --> <option value="Eritrea">Eritrea</option><!-- [et_pb_line_break_holder] --> <option value="Estonia">Estonia</option><!-- [et_pb_line_break_holder] --> <option value="Ethiopia">Ethiopia</option><!-- [et_pb_line_break_holder] --> <option value="Falkland Islands">Falkland Islands</option><!-- [et_pb_line_break_holder] --> <option value="Faroe Islands">Faroe Islands</option><!-- [et_pb_line_break_holder] --> <option value="Fiji">Fiji</option><!-- [et_pb_line_break_holder] --> <option value="Finland">Finland</option><!-- [et_pb_line_break_holder] --> <option value="France">France</option><!-- [et_pb_line_break_holder] --> <option value="French Guiana">French Guiana</option><!-- [et_pb_line_break_holder] --> <option value="French Polynesia">French Polynesia</option><!-- [et_pb_line_break_holder] --> <option value="French Southern Ter">French Southern Ter</option><!-- [et_pb_line_break_holder] --> <option value="Gabon">Gabon</option><!-- [et_pb_line_break_holder] --> <option value="Gambia">Gambia</option><!-- [et_pb_line_break_holder] --> <option value="Georgia">Georgia</option><!-- [et_pb_line_break_holder] --> <option value="Germany">Germany</option><!-- [et_pb_line_break_holder] --> <option value="Ghana">Ghana</option><!-- [et_pb_line_break_holder] --> <option value="Gibraltar">Gibraltar</option><!-- [et_pb_line_break_holder] --> <option value="Great Britain">Great Britain</option><!-- [et_pb_line_break_holder] --> <option value="Greece">Greece</option><!-- [et_pb_line_break_holder] --> <option value="Greenland">Greenland</option><!-- [et_pb_line_break_holder] --> <option value="Grenada">Grenada</option><!-- [et_pb_line_break_holder] --> <option value="Guadeloupe">Guadeloupe</option><!-- [et_pb_line_break_holder] --> <option value="Guam">Guam</option><!-- [et_pb_line_break_holder] --> <option value="Guatemala">Guatemala</option><!-- [et_pb_line_break_holder] --> <option value="Guinea">Guinea</option><!-- [et_pb_line_break_holder] --> <option value="Guyana">Guyana</option><!-- [et_pb_line_break_holder] --> <option value="Haiti">Haiti</option><!-- [et_pb_line_break_holder] --> <option value="Hawaii">Hawaii</option><!-- [et_pb_line_break_holder] --> <option value="Honduras">Honduras</option><!-- [et_pb_line_break_holder] --> <option value="Hong Kong">Hong Kong</option><!-- [et_pb_line_break_holder] --> <option value="Hungary">Hungary</option><!-- [et_pb_line_break_holder] --> <option value="Iceland">Iceland</option><!-- [et_pb_line_break_holder] --> <option value="India">India</option><!-- [et_pb_line_break_holder] --> <option value="Indonesia">Indonesia</option><!-- [et_pb_line_break_holder] --> <option value="Iran">Iran</option><!-- [et_pb_line_break_holder] --> <option value="Iraq">Iraq</option><!-- [et_pb_line_break_holder] --> <option value="Ireland">Ireland</option><!-- [et_pb_line_break_holder] --> <option value="Isle of Man">Isle of Man</option><!-- [et_pb_line_break_holder] --> <option value="Israel">Israel</option><!-- [et_pb_line_break_holder] --> <option value="Italy">Italy</option><!-- [et_pb_line_break_holder] --> <option value="Jamaica">Jamaica</option><!-- [et_pb_line_break_holder] --> <option value="Japan">Japan</option><!-- [et_pb_line_break_holder] --> <option value="Jordan">Jordan</option><!-- [et_pb_line_break_holder] --> <option value="Kazakhstan">Kazakhstan</option><!-- [et_pb_line_break_holder] --> <option value="Kenya">Kenya</option><!-- [et_pb_line_break_holder] --> <option value="Kiribati">Kiribati</option><!-- [et_pb_line_break_holder] --> <option value="Korea North">Korea North</option><!-- [et_pb_line_break_holder] --> <option value="Korea Sout">Korea South</option><!-- [et_pb_line_break_holder] --> <option value="Kuwait">Kuwait</option><!-- [et_pb_line_break_holder] --> <option value="Kyrgyzstan">Kyrgyzstan</option><!-- [et_pb_line_break_holder] --> <option value="Laos">Laos</option><!-- [et_pb_line_break_holder] --> <option value="Latvia">Latvia</option><!-- [et_pb_line_break_holder] --> <option value="Lebanon">Lebanon</option><!-- [et_pb_line_break_holder] --> <option value="Lesotho">Lesotho</option><!-- [et_pb_line_break_holder] --> <option value="Liberia">Liberia</option><!-- [et_pb_line_break_holder] --> <option value="Libya">Libya</option><!-- [et_pb_line_break_holder] --> <option value="Liechtenstein">Liechtenstein</option><!-- [et_pb_line_break_holder] --> <option value="Lithuania">Lithuania</option><!-- [et_pb_line_break_holder] --> <option value="Luxembourg">Luxembourg</option><!-- [et_pb_line_break_holder] --> <option value="Macau">Macau</option><!-- [et_pb_line_break_holder] --> <option value="Macedonia">Macedonia</option><!-- [et_pb_line_break_holder] --> <option value="Madagascar">Madagascar</option><!-- [et_pb_line_break_holder] --> <option value="Malaysia">Malaysia</option><!-- [et_pb_line_break_holder] --> <option value="Malawi">Malawi</option><!-- [et_pb_line_break_holder] --> <option value="Maldives">Maldives</option><!-- [et_pb_line_break_holder] --> <option value="Mali">Mali</option><!-- [et_pb_line_break_holder] --> <option value="Malta">Malta</option><!-- [et_pb_line_break_holder] --> <option value="Marshall Islands">Marshall Islands</option><!-- [et_pb_line_break_holder] --> <option value="Martinique">Martinique</option><!-- [et_pb_line_break_holder] --> <option value="Mauritania">Mauritania</option><!-- [et_pb_line_break_holder] --> <option value="Mauritius">Mauritius</option><!-- [et_pb_line_break_holder] --> <option value="Mayotte">Mayotte</option><!-- [et_pb_line_break_holder] --> <option value="Mexico">Mexico</option><!-- [et_pb_line_break_holder] --> <option value="Midway Islands">Midway Islands</option><!-- [et_pb_line_break_holder] --> <option value="Moldova">Moldova</option><!-- [et_pb_line_break_holder] --> <option value="Monaco">Monaco</option><!-- [et_pb_line_break_holder] --> <option value="Mongolia">Mongolia</option><!-- [et_pb_line_break_holder] --> <option value="Montserrat">Montserrat</option><!-- [et_pb_line_break_holder] --> <option value="Morocco">Morocco</option><!-- [et_pb_line_break_holder] --> <option value="Mozambique">Mozambique</option><!-- [et_pb_line_break_holder] --> <option value="Myanmar">Myanmar</option><!-- [et_pb_line_break_holder] --> <option value="Nambia">Nambia</option><!-- [et_pb_line_break_holder] --> <option value="Nauru">Nauru</option><!-- [et_pb_line_break_holder] --> <option value="Nepal">Nepal</option><!-- [et_pb_line_break_holder] --> <option value="Netherland Antilles">Netherland Antilles</option><!-- [et_pb_line_break_holder] --> <option value="Netherlands">Netherlands (Holland, Europe)</option><!-- [et_pb_line_break_holder] --> <option value="Nevis">Nevis</option><!-- [et_pb_line_break_holder] --> <option value="New Caledonia">New Caledonia</option><!-- [et_pb_line_break_holder] --> <option value="New Zealand">New Zealand</option><!-- [et_pb_line_break_holder] --> <option value="Nicaragua">Nicaragua</option><!-- [et_pb_line_break_holder] --> <option value="Niger">Niger</option><!-- [et_pb_line_break_holder] --> <option value="Nigeria">Nigeria</option><!-- [et_pb_line_break_holder] --> <option value="Niue">Niue</option><!-- [et_pb_line_break_holder] --> <option value="Norfolk Island">Norfolk Island</option><!-- [et_pb_line_break_holder] --> <option value="Norway">Norway</option><!-- [et_pb_line_break_holder] --> <option value="Oman">Oman</option><!-- [et_pb_line_break_holder] --> <option value="Pakistan">Pakistan</option><!-- [et_pb_line_break_holder] --> <option value="Palau Island">Palau Island</option><!-- [et_pb_line_break_holder] --> <option value="Palestine">Palestine</option><!-- [et_pb_line_break_holder] --> <option value="Panama">Panama</option><!-- [et_pb_line_break_holder] --> <option value="Papua New Guinea">Papua New Guinea</option><!-- [et_pb_line_break_holder] --> <option value="Paraguay">Paraguay</option><!-- [et_pb_line_break_holder] --> <option value="Peru">Peru</option><!-- [et_pb_line_break_holder] --> <option value="Phillipines">Philippines</option><!-- [et_pb_line_break_holder] --> <option value="Pitcairn Island">Pitcairn Island</option><!-- [et_pb_line_break_holder] --> <option value="Poland">Poland</option><!-- [et_pb_line_break_holder] --> <option value="Portugal">Portugal</option><!-- [et_pb_line_break_holder] --> <option value="Puerto Rico">Puerto Rico</option><!-- [et_pb_line_break_holder] --> <option value="Qatar">Qatar</option><!-- [et_pb_line_break_holder] --> <option value="Republic of Montenegro">Republic of Montenegro</option><!-- [et_pb_line_break_holder] --> <option value="Republic of Serbia">Republic of Serbia</option><!-- [et_pb_line_break_holder] --> <option value="Reunion">Reunion</option><!-- [et_pb_line_break_holder] --> <option value="Romania">Romania</option><!-- [et_pb_line_break_holder] --> <option value="Russia">Russia</option><!-- [et_pb_line_break_holder] --> <option value="Rwanda">Rwanda</option><!-- [et_pb_line_break_holder] --> <option value="St Barthelemy">St Barthelemy</option><!-- [et_pb_line_break_holder] --> <option value="St Eustatius">St Eustatius</option><!-- [et_pb_line_break_holder] --> <option value="St Helena">St Helena</option><!-- [et_pb_line_break_holder] --> <option value="St Kitts-Nevis">St Kitts-Nevis</option><!-- [et_pb_line_break_holder] --> <option value="St Lucia">St Lucia</option><!-- [et_pb_line_break_holder] --> <option value="St Maarten">St Maarten</option><!-- [et_pb_line_break_holder] --> <option value="St Pierre & Miquelon">St Pierre & Miquelon</option><!-- [et_pb_line_break_holder] --> <option value="St Vincent & Grenadines">St Vincent & Grenadines</option><!-- [et_pb_line_break_holder] --> <option value="Saipan">Saipan</option><!-- [et_pb_line_break_holder] --> <option value="Samoa">Samoa</option><!-- [et_pb_line_break_holder] --> <option value="Samoa American">Samoa American</option><!-- [et_pb_line_break_holder] --> <option value="San Marino">San Marino</option><!-- [et_pb_line_break_holder] --> <option value="Sao Tome & Principe">Sao Tome & Principe</option><!-- [et_pb_line_break_holder] --> <option value="Saudi Arabia">Saudi Arabia</option><!-- [et_pb_line_break_holder] --> <option value="Senegal">Senegal</option><!-- [et_pb_line_break_holder] --> <option value="Serbia">Serbia</option><!-- [et_pb_line_break_holder] --> <option value="Seychelles">Seychelles</option><!-- [et_pb_line_break_holder] --> <option value="Sierra Leone">Sierra Leone</option><!-- [et_pb_line_break_holder] --> <option value="Singapore">Singapore</option><!-- [et_pb_line_break_holder] --> <option value="Slovakia">Slovakia</option><!-- [et_pb_line_break_holder] --> <option value="Slovenia">Slovenia</option><!-- [et_pb_line_break_holder] --> <option value="Solomon Islands">Solomon Islands</option><!-- [et_pb_line_break_holder] --> <option value="Somalia">Somalia</option><!-- [et_pb_line_break_holder] --> <option value="South Africa">South Africa</option><!-- [et_pb_line_break_holder] --> <option value="Spain">Spain</option><!-- [et_pb_line_break_holder] --> <option value="Sri Lanka">Sri Lanka</option><!-- [et_pb_line_break_holder] --> <option value="Sudan">Sudan</option><!-- [et_pb_line_break_holder] --> <option value="Suriname">Suriname</option><!-- [et_pb_line_break_holder] --> <option value="Swaziland">Swaziland</option><!-- [et_pb_line_break_holder] --> <option value="Sweden">Sweden</option><!-- [et_pb_line_break_holder] --> <option value="Switzerland">Switzerland</option><!-- [et_pb_line_break_holder] --> <option value="Syria">Syria</option><!-- [et_pb_line_break_holder] --> <option value="Tahiti">Tahiti</option><!-- [et_pb_line_break_holder] --> <option value="Taiwan">Taiwan</option><!-- [et_pb_line_break_holder] --> <option value="Tajikistan">Tajikistan</option><!-- [et_pb_line_break_holder] --> <option value="Tanzania">Tanzania</option><!-- [et_pb_line_break_holder] --> <option value="Thailand">Thailand</option><!-- [et_pb_line_break_holder] --> <option value="Togo">Togo</option><!-- [et_pb_line_break_holder] --> <option value="Tokelau">Tokelau</option><!-- [et_pb_line_break_holder] --> <option value="Tonga">Tonga</option><!-- [et_pb_line_break_holder] --> <option value="Trinidad & Tobago">Trinidad & Tobago</option><!-- [et_pb_line_break_holder] --> <option value="Tunisia">Tunisia</option><!-- [et_pb_line_break_holder] --> <option value="Turkey">Turkey</option><!-- [et_pb_line_break_holder] --> <option value="Turkmenistan">Turkmenistan</option><!-- [et_pb_line_break_holder] --> <option value="Turks & Caicos Is">Turks & Caicos Is</option><!-- [et_pb_line_break_holder] --> <option value="Tuvalu">Tuvalu</option><!-- [et_pb_line_break_holder] --> <option value="Uganda">Uganda</option><!-- [et_pb_line_break_holder] --> <option value="Ukraine">Ukraine</option><!-- [et_pb_line_break_holder] --> <option value="United Arab Erimates">United Arab Emirates</option><!-- [et_pb_line_break_holder] --> <option value="United Kingdom">United Kingdom</option><!-- [et_pb_line_break_holder] --> <option value="United States of America">United States of America</option><!-- [et_pb_line_break_holder] --> <option value="Uraguay">Uruguay</option><!-- [et_pb_line_break_holder] --> <option value="Uzbekistan">Uzbekistan</option><!-- [et_pb_line_break_holder] --> <option value="Vanuatu">Vanuatu</option><!-- [et_pb_line_break_holder] --> <option value="Vatican City State">Vatican City State</option><!-- [et_pb_line_break_holder] --> <option value="Venezuela">Venezuela</option><!-- [et_pb_line_break_holder] --> <option value="Vietnam">Vietnam</option><!-- [et_pb_line_break_holder] --> <option value="Virgin Islands (Brit)">Virgin Islands (Brit)</option><!-- [et_pb_line_break_holder] --> <option value="Virgin Islands (USA)">Virgin Islands (USA)</option><!-- [et_pb_line_break_holder] --> <option value="Wake Island">Wake Island</option><!-- [et_pb_line_break_holder] --> <option value="Wallis & Futana Is">Wallis & Futana Is</option><!-- [et_pb_line_break_holder] --> <option value="Yemen">Yemen</option><!-- [et_pb_line_break_holder] --> <option value="Zaire">Zaire</option><!-- [et_pb_line_break_holder] --> <option value="Zambia">Zambia</option><!-- [et_pb_line_break_holder] --> <option value="Zimbabwe">Zimbabwe</option><!-- [et_pb_line_break_holder] --> </select><!-- [et_pb_line_break_holder] --> </td></tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td class="label" id="labelForm"><p style="margin:0;color:#7a7a7a;">City *</p></td><!-- [et_pb_line_break_holder] --> <td><input type="text" id="city" name="city" value="" pattern="^[A-Za-z ]+$" required=""></td><!-- [et_pb_line_break_holder] --> <td style="width:5%"> </td><!-- [et_pb_line_break_holder] --> <td class="label" id="labelForm"><p style="margin:0;color:#7a7a7a;">Email *</p></td><!-- [et_pb_line_break_holder] --> <td><input type="text" id="email_id" name="email_id" placeholder="Enter your Email-id" value="" pattern="^([A-Za-z0-9_\-\.])+\@([A-Za-z0-9_\-\.])+\.([A-Za-z]{2,4})$" required="" oninvalid="setCustomValidity('Example: noname@example.com')" onchange="try{setCustomValidity('')}catch(e){}"></td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td class="label" id="labelForm"><p style="margin:0;color:#7a7a7a;">State *</p></td><!-- [et_pb_line_break_holder] --> <td><input type="text" id="state" name="state" value="" pattern="^[A-Za-z ]+$" required=""></td><!-- [et_pb_line_break_holder] --> <td style="width:5%"> </td><!-- [et_pb_line_break_holder] --> <td class="label" id="labelForm"><label>Phone Number *</label></td><!-- [et_pb_line_break_holder] --> <td><input type="tel" id="phone" name="phone" value="" placeholder="Enter your telephone number with country code." pattern="[\+]([0-9]{5,})" required="" oninvalid="setCustomValidity('Write the plus sign before the country code. Example: +628163100000')" onchange="try{setCustomValidity('')}catch(e){}"></td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </tbody></table><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div>

<p>What is your connection to kidney disease ? </p><!-- [et_pb_line_break_holder] --><br><!-- [et_pb_line_break_holder] -->  </div><!-- [et_pb_line_break_holder] --> <div class="donatecontent"><!-- [et_pb_line_break_holder] --> <div style="width:50%;float:left;height:100%"><!-- [et_pb_line_break_holder] --> <input type="radio" name="connection" value="one" required=""><label>I have kidney disease</label><br><br><!-- [et_pb_line_break_holder] --> <input type="radio" name="connection" value="two"><label>I have a parent with kidney disease</label><br><br><!-- [et_pb_line_break_holder] --> <input type="radio" name="connection" value="three"><label>I have a friend/loved one with kidney disease</label><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div style="width:50%;float:left;height:100%"><!-- [et_pb_line_break_holder] --> <input type="radio" name="connection" value="four"><label>I work with patients with kidney disease</label><br><br><!-- [et_pb_line_break_holder] --> <input type="radio" name="connection" value="five"><label>Someone I know passed away from kidney disease</label><br><br><!-- [et_pb_line_break_holder] --> <input type="radio" name="connection" value="six"><label>I have no personal connection to kidney disease</label><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --><br><!-- [et_pb_line_break_holder] --><br><!-- [et_pb_line_break_holder] --><p>   </p><!-- [et_pb_line_break_holder] --> <input type="submit" value="Proceed to Paypal" id="submitdo" name="action"><!-- [et_pb_line_break_holder] --> </form>