|
| 1 | +<!DOCTYPE html> |
| 2 | +<html lang="en"> |
| 3 | +<head> |
| 4 | + <meta charset="UTF-8"> |
| 5 | + <title>Registration Page</title> |
| 6 | + <style> |
| 7 | + body { |
| 8 | + font-family: Arial, Helvetica, sans-serif; |
| 9 | + background-color: #f5f5f5; |
| 10 | + margin: 0; |
| 11 | + padding: 30px; |
| 12 | + } |
| 13 | + |
| 14 | + .page-track { |
| 15 | + font-size: 14px; |
| 16 | + margin-bottom: 10px; |
| 17 | + } |
| 18 | + |
| 19 | + .required-hint { |
| 20 | + color: #b50000; |
| 21 | + font-size: 13px; |
| 22 | + margin-bottom: 12px; |
| 23 | + } |
| 24 | + |
| 25 | + .form-wrapper { |
| 26 | + background-color: #e9e9e9; |
| 27 | + border: 1px solid #c8c8c8; |
| 28 | + max-width: 640px; |
| 29 | + padding: 25px 40px; |
| 30 | + margin: 0 auto; |
| 31 | + } |
| 32 | + |
| 33 | + h2 { |
| 34 | + color: #d21515; |
| 35 | + margin-top: 30px; |
| 36 | + margin-bottom: 15px; |
| 37 | + font-size: 20px; |
| 38 | + } |
| 39 | + |
| 40 | + fieldset { |
| 41 | + border: none; |
| 42 | + padding: 0; |
| 43 | + margin: 0; |
| 44 | + } |
| 45 | + |
| 46 | + .form-grid { |
| 47 | + display: grid; |
| 48 | + grid-template-columns: 160px 1fr; |
| 49 | + gap: 8px 14px; |
| 50 | + margin-bottom: 16px; |
| 51 | + } |
| 52 | + |
| 53 | + label { |
| 54 | + font-size: 14px; |
| 55 | + align-self: center; |
| 56 | + } |
| 57 | + |
| 58 | + input[type="text"], |
| 59 | + input[type="email"], |
| 60 | + input[type="tel"], |
| 61 | + select, |
| 62 | + textarea { |
| 63 | + padding: 6px; |
| 64 | + border: 1px solid #b6b6b6; |
| 65 | + border-radius: 2px; |
| 66 | + font-size: 14px; |
| 67 | + width: 100%; |
| 68 | + box-sizing: border-box; |
| 69 | + } |
| 70 | + |
| 71 | + textarea { |
| 72 | + resize: vertical; |
| 73 | + min-height: 90px; |
| 74 | + } |
| 75 | + |
| 76 | + .inline-group { |
| 77 | + display: flex; |
| 78 | + flex-wrap: wrap; |
| 79 | + align-items: center; |
| 80 | + gap: 14px; |
| 81 | + font-size: 14px; |
| 82 | + } |
| 83 | + |
| 84 | + .inline-group label { |
| 85 | + margin-right: 4px; |
| 86 | + align-self: center; |
| 87 | + } |
| 88 | + |
| 89 | + .small-field { |
| 90 | + max-width: 160px; |
| 91 | + } |
| 92 | + |
| 93 | + .checkbox-list, |
| 94 | + .radio-list { |
| 95 | + margin-bottom: 16px; |
| 96 | + font-size: 14px; |
| 97 | + } |
| 98 | + |
| 99 | + .form-actions { |
| 100 | + display: flex; |
| 101 | + justify-content: flex-start; |
| 102 | + gap: 12px; |
| 103 | + margin-top: 20px; |
| 104 | + } |
| 105 | + |
| 106 | + button { |
| 107 | + background-color: #d6d6d6; |
| 108 | + border: 1px solid #a5a5a5; |
| 109 | + padding: 6px 20px; |
| 110 | + font-size: 14px; |
| 111 | + cursor: pointer; |
| 112 | + } |
| 113 | + |
| 114 | + button:hover { |
| 115 | + background-color: #c0c0c0; |
| 116 | + } |
| 117 | + |
| 118 | + hr { |
| 119 | + border: none; |
| 120 | + border-top: 1px solid #c2c2c2; |
| 121 | + margin: 24px 0; |
| 122 | + } |
| 123 | + </style> |
| 124 | +</head> |
| 125 | +<body> |
| 126 | + <div class="required-hint">* - Denotes Required Information</div> |
| 127 | + <div class="page-track">> 1 Donation > 2 Confirmation > Thank You!</div> |
| 128 | + |
| 129 | + <div class="form-wrapper"> |
| 130 | + <form> |
| 131 | + <section> |
| 132 | + <h2>Donor Information</h2> |
| 133 | + <fieldset> |
| 134 | + <div class="form-grid"> |
| 135 | + <label for="first-name">First Name*</label> |
| 136 | + <input id="first-name" name="first-name" type="text" required> |
| 137 | + |
| 138 | + <label for="last-name">Last Name*</label> |
| 139 | + <input id="last-name" name="last-name" type="text" required> |
| 140 | + |
| 141 | + <label for="company">Company</label> |
| 142 | + <input id="company" name="company" type="text"> |
| 143 | + |
| 144 | + <label for="address1">Address 1*</label> |
| 145 | + <input id="address1" name="address1" type="text" required> |
| 146 | + |
| 147 | + <label for="address2">Address 2</label> |
| 148 | + <input id="address2" name="address2" type="text"> |
| 149 | + |
| 150 | + <label for="city">City*</label> |
| 151 | + <input id="city" name="city" type="text" required> |
| 152 | + |
| 153 | + <label for="state">State*</label> |
| 154 | + <select id="state" name="state" required> |
| 155 | + <option value="">Select a State</option> |
| 156 | + <option>California</option> |
| 157 | + <option>Florida</option> |
| 158 | + <option>Georgia</option> |
| 159 | + <option>Hawaii</option> |
| 160 | + <option>New Mexico</option> |
| 161 | + <option>New York</option> |
| 162 | + <option>Texas</option> |
| 163 | + <option>Washington</option> |
| 164 | + </select> |
| 165 | + |
| 166 | + <label for="zip">Zip Code*</label> |
| 167 | + <input id="zip" name="zip" type="text" required class="small-field"> |
| 168 | + |
| 169 | + <label for="country">Country*</label> |
| 170 | + <select id="country" name="country" required> |
| 171 | + <option value="">Select a Country</option> |
| 172 | + <option>Bangladesh</option> |
| 173 | + <option>India</option> |
| 174 | + <option>Pakistan</option> |
| 175 | + <option>Bhutan</option> |
| 176 | + <option>Maldives</option> |
| 177 | + <option>Nepal</option> |
| 178 | + <option>Sri Lanka</option> |
| 179 | + <option>Afghanistan</option> |
| 180 | + <option>United States</option> |
| 181 | + <option>Canada</option> |
| 182 | + <option>United Kingdom</option> |
| 183 | + <option>Australia</option> |
| 184 | + <option>China</option> |
| 185 | + <option>Japan</option> |
| 186 | + <option>Germany</option> |
| 187 | + <option>France</option> |
| 188 | + <option>Italy</option> |
| 189 | + <option>Spain</option> |
| 190 | + <option>Brazil</option> |
| 191 | + <option>South Africa</option> |
| 192 | + <option>Mexico</option> |
| 193 | + <option>Other</option> |
| 194 | + </select> |
| 195 | + |
| 196 | + <label for="phone">Phone</label> |
| 197 | + <input id="phone" name="phone" type="tel"> |
| 198 | + |
| 199 | + <label for="fax">Fax</label> |
| 200 | + <input id="fax" name="fax" type="tel"> |
| 201 | + |
| 202 | + <label for="email">Email*</label> |
| 203 | + <input id="email" name="email" type="email" required> |
| 204 | + </div> |
| 205 | + </fieldset> |
| 206 | + |
| 207 | + <div class="radio-list"> |
| 208 | + <span>Donation Amount*</span> |
| 209 | + <div class="inline-group"> |
| 210 | + <label><input type="radio" name="amount" value="0" checked> None</label> |
| 211 | + <label><input type="radio" name="amount" value="50"> $50</label> |
| 212 | + <label><input type="radio" name="amount" value="75"> $75</label> |
| 213 | + <label><input type="radio" name="amount" value="100"> $100</label> |
| 214 | + <label><input type="radio" name="amount" value="250"> $250</label> |
| 215 | + <label><input type="radio" name="amount" value="other"> Other</label> |
| 216 | + <label>Other Amount $ <input type="text" name="amount-other" class="small-field"></label> |
| 217 | + </div> |
| 218 | + </div> |
| 219 | + |
| 220 | + <div class="inline-group"> |
| 221 | + <label><input type="checkbox" name="recurring"> I am interested in giving on a regular basis.</label> |
| 222 | + <label>Monthly Credit Card $ <input type="text" name="monthly-amount" class="small-field"></label> |
| 223 | + <label>For <input type="text" name="monthly-months" class="small-field"> months</label> |
| 224 | + </div> |
| 225 | + </section> |
| 226 | + |
| 227 | + <hr> |
| 228 | + |
| 229 | + <section> |
| 230 | + <h2>Honorarium and Memorial Donation Information</h2> |
| 231 | + <div class="inline-group"> |
| 232 | + <span>I would like to make this</span> |
| 233 | + <label><input type="radio" name="honor-type" value="honor"> To Honor</label> |
| 234 | + <label><input type="radio" name="honor-type" value="memory"> In Memory of</label> |
| 235 | + </div> |
| 236 | + |
| 237 | + <div class="inline-group" style="margin-top: 10px;"> |
| 238 | + <span>Acknowledge donation to</span> |
| 239 | + <select name="acknowledge-title" class="small-field"> |
| 240 | + <option value="">Select</option> |
| 241 | + <option>Mr.</option> |
| 242 | + <option>Mrs.</option> |
| 243 | + <option>Ms.</option> |
| 244 | + <option>Dr.</option> |
| 245 | + <option>Prof.</option> |
| 246 | + </select> |
| 247 | + </div> |
| 248 | + |
| 249 | + <div class="form-grid" style="margin-top: 10px;"> |
| 250 | + <label for="ack-name">Name</label> |
| 251 | + <input id="ack-name" name="ack-name" type="text"> |
| 252 | + |
| 253 | + <label for="ack-address">Address</label> |
| 254 | + <input id="ack-address" name="ack-address" type="text"> |
| 255 | + |
| 256 | + <label for="ack-city">City</label> |
| 257 | + <input id="ack-city" name="ack-city" type="text"> |
| 258 | + |
| 259 | + <label for="ack-state">State</label> |
| 260 | + <select id="ack-state" name="ack-state"> |
| 261 | + <option>California</option> |
| 262 | + <option>Florida</option> |
| 263 | + <option>Georgia</option> |
| 264 | + <option>Hawaii</option> |
| 265 | + <option>New Mexico</option> |
| 266 | + <option>New York</option> |
| 267 | + <option>Texas</option> |
| 268 | + <option>Washington</option> |
| 269 | + </select> |
| 270 | + |
| 271 | + <label for="ack-zip">Zip</label> |
| 272 | + <input id="ack-zip" name="ack-zip" type="text" class="small-field"> |
| 273 | + </div> |
| 274 | + </section> |
| 275 | + |
| 276 | + <hr> |
| 277 | + |
| 278 | + <section> |
| 279 | + <h2>Additional Information</h2> |
| 280 | + <p>Please enter your name, company or organization as you would like it to appear in our publications:</p> |
| 281 | + |
| 282 | + <div class="form-grid" style="margin-bottom: 10px;"> |
| 283 | + <label for="public-name">Name</label> |
| 284 | + <input id="public-name" name="public-name" type="text"> |
| 285 | + </div> |
| 286 | + |
| 287 | + <div class="checkbox-list"> |
| 288 | + <label><input type="checkbox" name="anonymous"> I would like my gift to remain anonymous.</label> <br> |
| 289 | + <label><input type="checkbox" name="matching"> My employer offers a matching gift program. I will mail the matching gift form.</label> <br> |
| 290 | + <label><input type="checkbox" name="no-mail"> Please save the cost of acknowledging this gift by not mailing a thank you letter.</label> |
| 291 | + </div> |
| 292 | + |
| 293 | + <label for="comments">Comments</label> |
| 294 | + <textarea id="comments" name="comments" placeholder="Please enter any questions or feedback here"></textarea> |
| 295 | + |
| 296 | + <div class="checkbox-list" style="margin-top: 16px;"> |
| 297 | + <div style="margin-bottom: 5px;"> |
| 298 | + <span style="margin-top: 10px;">How may we contact you?</span> <br> |
| 299 | + </div> |
| 300 | + <label><input type="checkbox" name="contact-email"> Email</label> <br> |
| 301 | + <label><input type="checkbox" name="contact-mail"> Postal Mail</label> <br> |
| 302 | + <label><input type="checkbox" name="contact-phone"> Telephone</label> <br> |
| 303 | + <label><input type="checkbox" name="contact-fax"> Fax</label> |
| 304 | + </div> |
| 305 | + |
| 306 | + <div class="checkbox-list"> |
| 307 | + <div style="margin-bottom: 5px;"> |
| 308 | + <span>I would like to receive newsletters and information about special events by:</span> <br> |
| 309 | + </div> |
| 310 | + <label><input type="checkbox" name="info-email"> Email</label> <br> |
| 311 | + <label><input type="checkbox" name="info-mail"> Postal Mail</label> |
| 312 | + </div> |
| 313 | + |
| 314 | + <div class="checkbox-list"> |
| 315 | + <label><input type="checkbox" name="volunteer"> I would like information about volunteering with the organization.</label> |
| 316 | + </div> |
| 317 | + </section> |
| 318 | + |
| 319 | + <div class="form-actions"> |
| 320 | + <button type="reset">Reset</button> |
| 321 | + <button type="submit">Continue</button> |
| 322 | + </div> |
| 323 | + </form> |
| 324 | + </div> |
| 325 | + |
| 326 | + <p style="font-size: 12px; margin-top: 18px; color: #505050;"> |
| 327 | + Donate online with confidence. You are on a secure server. If you have any problems or questions, please contact support. |
| 328 | + </p> |
| 329 | +</body> |
| 330 | +</html> |
0 commit comments