[give_form id="60" show_title="false" show_goal="true" display_style="modal"]
<div id="give-form-60-wrap" class="give-form-wrap give-display-modal">
<form id="give-form-60-1" class="give-form give-form-60 give-form-type-multi float-labels-enabled" action="https://www.jenniffer.com/presentation/jenniffer-gonzalez-colon-plataforma-de-salud/?payment-mode=paypal" data-id="60-1" data-currency_symbol="$" data-currency_code="USD" data-currency_position="before" data-thousands_separator="," data-decimal_separator="." data-number_decimals="2" method="post">
<!-- The following field is for robots only, invisible to humans: -->
<span class="give-hidden" style="display: none !important;">
<label for="give-form-honeypot-60"></label>
<input id="give-form-honeypot-60" type="text" name="give-honeypot"
class="give-honeypot give-hidden"/>
</span>
<input type="hidden" name="give-form-id-prefix" value="60-1"/>
<input type="hidden" name="give-form-id" value="60"/>
<input type="hidden" name="give-form-title" value="Donate from"/>
<input type="hidden" name="give-current-url" value="https://www.jenniffer.com/presentation/jenniffer-gonzalez-colon-plataforma-de-salud/"/>
<input type="hidden" name="give-form-url" value="https://www.jenniffer.com/presentation/jenniffer-gonzalez-colon-plataforma-de-salud/"/>
<input type="hidden" name="give-form-minimum"
value="1.00"/>
<input type="hidden" name="give-form-maximum"
value="2800.00"/>
<input type="hidden" name="give-form-hash" value="0ca6023cbb" data-time="1679962967" data-nonce-life="86400" data-donor-session="0"/><input type="hidden" name="give-price-id" value="2"/> <div class="give-total-wrap">
<div class="give-donation-amount form-row-wide">
<span class="give-currency-symbol give-currency-position-before">$</span> <label class="give-hidden" for="give-amount">Cantidad a donar:</label>
<input class="give-text-input give-amount-top" id="give-amount" name="give-amount" type="tel"
placeholder="" value="25.00" autocomplete="off">
</div>
</div>
<ul id="give-donation-level-button-wrap" class="give-donation-levels-wrap give-list-inline"><li><button type="button" data-price-id="0" class="give-donation-level-btn give-btn give-btn-level-0 " value="5.00" data-default="0">$5</button></li><li><button type="button" data-price-id="1" class="give-donation-level-btn give-btn give-btn-level-1 " value="10.00" data-default="0">$10</button></li><li><button type="button" data-price-id="2" class="give-donation-level-btn give-btn give-btn-level-2 give-default-level" value="25.00" data-default="1">$25</button></li><li><button type="button" data-price-id="3" class="give-donation-level-btn give-btn give-btn-level-3 " value="50.00" data-default="0">$50</button></li><li><button type="button" data-price-id="4" class="give-donation-level-btn give-btn give-btn-level-4 " value="100.00" data-default="0">$100</button></li><li><button type="button" data-price-id="custom" class="give-donation-level-btn give-btn give-btn-level-custom" value="custom">Otra Cantidad</button></li></ul><button type="button" class="give-btn give-btn-modal">Donar ahora</button>
<fieldset id="give-payment-mode-select"
style="display: none;" >
<legend
class="give-payment-mode-label">Seleccionar el método de pago <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-paypal-60-1"
value="paypal" checked='checked'>
<label for="give-gateway-paypal-60-1"
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>
Información personal </legend>
<p id="give-first-name-wrap" class="form-row form-row-first form-row-responsive">
<label class="give-label" for="give-first">
Nombre <span class="give-required-indicator">*</span>
<span class="give-tooltip hint--top hint--medium hint--bounce" aria-label="El nombre se usa para personalizar tu registro de donación." 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="Nombre"
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">
Apellidos <span class="give-tooltip hint--top hint--medium hint--bounce" aria-label="Los apellidos se usan para personalizar tu registro de donación." rel="tooltip"><i class="give-icon give-icon-question"></i></span> </label>
<input
class="give-input"
type="text"
name="give_last"
autocomplete="family-name"
id="give-last"
placeholder="Apellidos"
value=""
/>
</p>
<p id="give-email-wrap" class="form-row form-row-wide">
<label class="give-label" for="give-email">
Dirección de correo electrónico <span class="give-required-indicator">*</span>
<span class="give-tooltip hint--top hint--medium hint--bounce" aria-label="Enviaremos el recibo de la donación a esta dirección." 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="Dirección de correo electrónico"
id="give-email"
value=""
required aria-required="true" />
</p>
</fieldset>
<fieldset id="give-ffm-section">
<div id="phone-wrap" class="form-row give-ffm-form-row-responsive give-ffm-form-row-full phone"> <label class="give-label" for="ffm-phone">
Teléfono <span class="give-required-indicator">*</span> <span class="give-tooltip give-icon give-icon-question"
data-tooltip="Teléfono"></span>
</label>
<input
class="phone js-phone-domestic required"
id="ffm-phone" type="tel"
data-required="yes"
data-type="tel" required="required" name="phone"
placeholder="Telefono" value=""/>
</div><div id="patrono-wrap" class="form-row give-ffm-form-row-responsive give-ffm-form-row-full patrono"> <label class="give-label" for="ffm-patrono">
Patrono <span class="give-required-indicator">*</span> <span class="give-tooltip give-icon give-icon-question"
data-tooltip="Patrono"></span>
</label>
<input class="textfield required"
id="ffm-patrono" type="text"
data-required="yes"
data-type="text" required="required" name="patrono"
placeholder="Patrono" value=""
/>
</div><div id="posicin-wrap" class="form-row give-ffm-form-row-responsive give-ffm-form-row-full posicion"> <label class="give-label" for="ffm-posicin">
Posición <span class="give-required-indicator">*</span> <span class="give-tooltip give-icon give-icon-question"
data-tooltip="Posicion"></span>
</label>
<input class="textfield required"
id="ffm-posicin" type="text"
data-required="yes"
data-type="text" required="required" name="posicin"
placeholder="Posición" value=""
/>
</div>
</fieldset>
<fieldset id="give_cc_address" class="cc-address">
<legend>Datos de facturación</legend>
<p id="give-card-country-wrap" class="form-row form-row-wide">
<label for="billing_country" class="give-label">
País <span class="give-required-indicator">*</span>
<span class="give-tooltip give-icon give-icon-question"
data-tooltip="El país para tu dirección de facturación."></span>
</label>
<select
name="billing_country"
autocomplete="country"
id="billing_country"
class="billing-country billing_country give-select required"
required aria-required="true" >
<option value=""></option><option value="US" selected='selected'>Estados Unidos</option><option value="CA">Canadá</option><option value="GB">Reino Unido</option><option value="AF">Afganistán</option><option value="AL">Albania</option><option value="DZ">Argelia</option><option value="AS">Samoa Americana</option><option value="AD">Andorra</option><option value="AO">Angola</option><option value="AI">Anguila</option><option value="AQ">Antártida</option><option value="AG">Antigua y 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">Azerbaiyán</option><option value="BS">Bahamas</option><option value="BH">Bahrein</option><option value="BD">Bangladesh</option><option value="BB">Barbados</option><option value="BY">Bielorrusia</option><option value="BE">Bélgica</option><option value="BZ">Belice</option><option value="BJ">Benín</option><option value="BM">Bermudas</option><option value="BT">Bután</option><option value="BO">Bolivia</option><option value="BA">Bosnia y Herzegovina</option><option value="BW">Botswana</option><option value="BV">Isla Bouvet</option><option value="BR">Brasil</option><option value="IO">Territorio Británico del Océano Índico</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">Camboya</option><option value="CM">Camerún</option><option value="CV">Cabo Verde</option><option value="KY">Islas Caimán</option><option value="CF">República Centroafricana</option><option value="TD">Chad</option><option value="CL">Chile</option><option value="CN">China</option><option value="CX">Isla de Navidad</option><option value="CC">Islas Cocos</option><option value="CO">Colombia</option><option value="KM">Comoras</option><option value="CD">Congo, República Popular Democrática</option><option value="CG">Congo, República del </option><option value="CK">Islas Cook</option><option value="CR">Costa Rica</option><option value="CI">Costa de Marfil</option><option value="HR">Croacia/Hrvatska</option><option value="CU">Cuba</option><option value="CY">Isla de Chipre</option><option value="CZ">República Checa</option><option value="DK">Dinamarca</option><option value="DJ">Djibouti</option><option value="DM">Dominica</option><option value="DO">República Dominicana</option><option value="TP">Timor Oriental</option><option value="EC">Ecuador</option><option value="EG">Egipto</option><option value="GQ">Guinea Ecuatorial</option><option value="SV">El Salvador</option><option value="ER">Eritrea</option><option value="EE">Estonia</option><option value="ET">Etiopía</option><option value="FK">Islas Malvinas</option><option value="FO">Islas Faroe</option><option value="FJ">Fiyi</option><option value="FI">Finlandia</option><option value="FR">Francia</option><option value="GF">Guayana Francesa</option><option value="PF">Polinesia Francesa</option><option value="TF">Territorios Franceses del Sur</option><option value="GA">Gabón</option><option value="GM">Gambia</option><option value="GE">Georgia</option><option value="DE">Alemania</option><option value="GR">Grecia</option><option value="GH">Ghana</option><option value="GI">Gibraltar</option><option value="GL">Groenlandia</option><option value="GD">Granada</option><option value="GP">Guadalupe</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">Guayana</option><option value="HT">Haití</option><option value="HM">Islas Heard y McDonald</option><option value="VA">Santa Sede (Ciudad del Estado del Vaticano)</option><option value="HN">Honduras</option><option value="HK">Hong Kong</option><option value="HU">Hungría</option><option value="IS">Islandia</option><option value="IN">India</option><option value="ID">Indonesia</option><option value="IR">Irán</option><option value="IQ">Irak</option><option value="IE">Irlanda</option><option value="IM">Isla de Man</option><option value="IL">Israel</option><option value="IT">Italia</option><option value="JM">Jamaica</option><option value="JP">Japón</option><option value="JE">Jersey</option><option value="JO">Jordania</option><option value="KZ">Kazajistán</option><option value="KE">Kenia</option><option value="KI">Kiribati</option><option value="KW">Kuwait</option><option value="KG">Kirguistán</option><option value="LA">República Democrática Popular de Laos</option><option value="LV">Letonia</option><option value="LB">Líbano</option><option value="LS">Lesoto</option><option value="LR">Liberia</option><option value="LY">Yamahiriya Árabe Libia</option><option value="LI">Liechtenstein</option><option value="LT">Lituania</option><option value="LU">Luxemburgo</option><option value="MO">Macao</option><option value="MK">Macedonia</option><option value="MG">Madagascar</option><option value="MW">Malaui</option><option value="MY">Malasia</option><option value="MV">Maldivas</option><option value="ML">Mali</option><option value="MT">Malta</option><option value="MH">Islas Marshall</option><option value="MQ">Martinica</option><option value="MR">Mauritania</option><option value="MU">Mauricio</option><option value="YT">Mayotte</option><option value="MX">México</option><option value="FM">Micronesia</option><option value="MD">Moldavia, República de</option><option value="MC">Mónaco</option><option value="MN">Mongolia</option><option value="ME">Montenegro</option><option value="MS">Montserrat</option><option value="MA">Marruecos</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">Países Bajos</option><option value="AN">Antillas Holandesas</option><option value="NC">Nueva Caledonia</option><option value="NZ">Nueva Zelanda</option><option value="NI">Nicaragua</option><option value="NE">Níger</option><option value="NG">Nigeria</option><option value="NU">Niue</option><option value="NF">Isla Norfolk</option><option value="KP">Corea del Norte</option><option value="MP">Islas Marianas del Norte</option><option value="NO">Noruega</option><option value="OM">Omán</option><option value="PK">Pakistán</option><option value="PW">Palaos</option><option value="PS">Territorios Palestinos</option><option value="PA">Panamá</option><option value="PG">Papúa Nueva Guinea</option><option value="PY">Paraguay</option><option value="PE">Perú</option><option value="PH">Filipinas</option><option value="PN">Isla Pitcairn</option><option value="PL">Polonia</option><option value="PT">Portugal</option><option value="PR">Puerto Rico</option><option value="QA">Qatar</option><option value="RE">Isla Reunión</option><option value="RO">Rumanía</option><option value="RU">Federación Rusa</option><option value="RW">Ruanda</option><option value="SH">Santa Helena</option><option value="KN">San Cristóbal y Nieves</option><option value="LC">Santa Lucía</option><option value="PM">San Pedro y Miquelón</option><option value="VC">San Vicente y las Granadinas</option><option value="SM">San Marino</option><option value="ST">Santo Tomé y Príncipe</option><option value="SA">Arabia Saudita</option><option value="SN">Senegal</option><option value="RS">Serbia</option><option value="SC">Seychelles</option><option value="SL">Sierra Leona</option><option value="SG">Singapur</option><option value="SK">República Eslovaca</option><option value="SI">Eslovenia</option><option value="SB">Islas Salomón</option><option value="SO">Somalia</option><option value="ZA">Sudáfrica</option><option value="GS">Georgia del Sur</option><option value="KR">Corea del Sur</option><option value="ES">España</option><option value="LK">Sri Lanka</option><option value="SD">Sudán</option><option value="SR">Surinam</option><option value="SJ">Islas Svalbard y Jan Mayen</option><option value="SZ">Eswatini</option><option value="SE">Suecia</option><option value="CH">Suiza</option><option value="SY">República Árabe de Siria</option><option value="TW">Taiwán</option><option value="TJ">Tayikistán</option><option value="TZ">Tanzania</option><option value="TG">Togo</option><option value="TK">Tokelau</option><option value="TO">Tonga</option><option value="TH">Tailandia</option><option value="TT">Trinidad y Tobago</option><option value="TN">Túnez</option><option value="TR">Turquía</option><option value="TM">Turkmenistán</option><option value="TC">Islas Turcas y Caicos</option><option value="TV">Tuvalu</option><option value="UG">Uganda</option><option value="UA">Ucrania</option><option value="AE">Emiratos Árabes Unidos</option><option value="UY">Uruguay</option><option value="UM">Islas Ultramarinas Menores de los Estados Unidos</option><option value="UZ">Uzbekistán</option><option value="VU">Vanuatu</option><option value="VE">Venezuela</option><option value="VN">Vietnam</option><option value="VG">Islas Vírgenes (Británicas)</option><option value="VI">Islas Vírgenes (EE.UU.)</option><option value="WF">Islas Wallis y Futuna</option><option value="EH">Sahara Occidental</option><option value="WS">Samoa Occidental</option><option value="YE">Yemen</option><option value="YU">Yugoslavia</option><option value="ZM">Zambia</option><option value="ZW">Zimbabue</option> </select>
</p>
<p id="give-card-address-wrap" class="form-row form-row-wide">
<label for="card_address" class="give-label">
Dirección 1 <span class="give-required-indicator">*</span>
<span class="give-tooltip hint--top hint--medium hint--bounce" aria-label="La dirección de facturación principal para tu tarjeta de crédito." rel="tooltip"><i class="give-icon give-icon-question"></i></span> </label>
<input
type="text"
id="card_address"
name="card_address"
autocomplete="address-line1"
class="card-address give-input required"
placeholder="Dirección línea 1"
value=""
required aria-required="true" />
</p>
<p id="give-card-address-2-wrap" class="form-row form-row-wide">
<label for="card_address_2" class="give-label">
Dirección 2 <span class="give-tooltip hint--top hint--large hint--bounce" aria-label="(opcional) La habitación, el número de apartamento, el apartado de correos (etc) asociado a tu dirección de facturación." rel="tooltip"><i class="give-icon give-icon-question"></i></span> </label>
<input
type="text"
id="card_address_2"
name="card_address_2"
autocomplete="address-line2"
class="card-address-2 give-input"
placeholder="Dirección línea 2"
value=""
/>
</p>
<p id="give-card-city-wrap" class="form-row form-row-wide">
<label for="card_city" class="give-label">
Ciudad <span class="give-required-indicator ">*</span>
<span class="give-tooltip hint--top hint--medium hint--bounce" aria-label="La ciudad para tu dirección de facturación." rel="tooltip"><i class="give-icon give-icon-question"></i></span> </label>
<input
type="text"
id="card_city"
name="card_city"
autocomplete="address-level2"
class="card-city give-input required"
placeholder="Ciudad"
value=""
required aria-required="true" />
</p>
<p id="give-card-state-wrap"
class="form-row form-row-first form-row-responsive ">
<label for="card_state" class="give-label">
<span class="state-label-text">Provincia</span>
<span
class="give-required-indicator ">*</span>
<span class="give-tooltip give-icon give-icon-question"
data-tooltip="El estado, provincia o condado para tu dirección de facturación."></span>
</label>
<select
name="card_state"
autocomplete="address-level1"
id="card_state"
class="card_state give-select required"
required aria-required="true" >
<option value=""></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" selected='selected'>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-card-zip-wrap" class="form-row form-row-last form-row-responsive">
<label for="card_zip" class="give-label">
Código postal <span class="give-required-indicator">*</span>
<span class="give-tooltip hint--top hint--medium hint--bounce" aria-label="El código postal para tu dirección de facturación." rel="tooltip"><i class="give-icon give-icon-question"></i></span> </label>
<input
type="text"
size="4"
id="card_zip"
name="card_zip"
autocomplete="postal-code"
class="card-zip give-input required"
placeholder="Código postal"
value=""
required aria-required="true" />
</p>
</fieldset>
<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 de la donación: </span>
<span class="give-final-total-amount"
data-total="25.00">
$25.00 </span>
</p>
<input type="hidden" name="give_action" value="purchase"/>
<input type="hidden" name="give-gateway" value="paypal"/>
<div class="give-submit-button-wrap give-clearfix">
<input type="submit" class="give-submit give-btn" id="give-purchase-button" name="give-purchase"
value="¡Listo!" data-before-validation-label="¡Listo!"/>
<span class="give-loading-animation"></span>
</div>
</fieldset>
</div>
</form>
</div><!--end #give-form-60-->
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