{"id":768,"date":"2023-08-10T15:22:52","date_gmt":"2023-08-10T15:22:52","guid":{"rendered":"https:\/\/pediatricbrainfoundation.org\/archive\/organization-contact\/"},"modified":"2023-08-10T15:22:52","modified_gmt":"2023-08-10T15:22:52","slug":"organization-contact","status":"publish","type":"page","link":"https:\/\/pediatricbrainfoundation.org\/archive\/organization-contact\/","title":{"rendered":"Organization Contact"},"content":{"rendered":"<div class=\"row-fluid\">\n<section class=\"content-top span12\">\n      <a id=\"main-content\"><\/a><\/p>\n<h1 class=\"page-header\">Organization Contact<\/h1>\n<\/section><\/div>\n<div class=\"row-fluid\">\n<section class=\"main-content span12\">\n<section id=\"block-system-main\" class=\"block-system block-page-content clearfix\">\n<div class=\"section-in\">\n<div class=\"section-inn\">\n<div class=\"section-innn\">\n<article id=\"node-5734\" class=\"node node-webform clearfix\">\n<form class=\"webform-client-form\" enctype=\"multipart\/form-data\" action=\"https:\/\/pediatricbrainfoundation.org\/archive\/organization-contact\/\" method=\"post\" id=\"webform-client-form-5734\" accept-charset=\"UTF-8\">\n<div>\n<div class=\"form-item webform-component webform-component-textfield\" id=\"webform-component-civicrm-1-contact-1-contact-organization-name\">\n  <label for=\"edit-submitted-civicrm-1-contact-1-contact-organization-name\" class=\"control-label\">Organization Name <\/label><br \/>\n <input type=\"text\" id=\"edit-submitted-civicrm-1-contact-1-contact-organization-name\" name=\"submitted[civicrm_1_contact_1_contact_organization_name]\" value=\"\" size=\"20\" maxlength=\"128\" class=\"form-text\"\/>\n<\/div>\n<div class=\"form-item webform-component webform-component-textfield\" id=\"webform-component-civicrm-1-contact-1-cg2-custom-18\">\n  <label for=\"edit-submitted-civicrm-1-contact-1-cg2-custom-18\" class=\"control-label\">Primary Contact Name <\/label><br \/>\n <input type=\"text\" id=\"edit-submitted-civicrm-1-contact-1-cg2-custom-18\" name=\"submitted[civicrm_1_contact_1_cg2_custom_18]\" value=\"\" size=\"20\" maxlength=\"128\" class=\"form-text\"\/>\n<\/div>\n<div class=\"form-item webform-component webform-component-textfield\" id=\"webform-component-civicrm-1-contact-1-phone-phone\">\n  <label for=\"edit-submitted-civicrm-1-contact-1-phone-phone\" class=\"control-label\">Phone Number <\/label><br \/>\n <input type=\"text\" id=\"edit-submitted-civicrm-1-contact-1-phone-phone\" name=\"submitted[civicrm_1_contact_1_phone_phone]\" value=\"\" size=\"20\" maxlength=\"128\" class=\"form-text\"\/>\n<\/div>\n<div class=\"form-item webform-component webform-component-textfield\" id=\"webform-component-civicrm-1-contact-1-website-url\">\n  <label for=\"edit-submitted-civicrm-1-contact-1-website-url\" class=\"control-label\">Website <\/label><br \/>\n <input type=\"text\" id=\"edit-submitted-civicrm-1-contact-1-website-url\" name=\"submitted[civicrm_1_contact_1_website_url]\" value=\"\" size=\"20\" maxlength=\"128\" class=\"form-text\"\/>\n<\/div>\n<div class=\"form-item webform-component webform-component-email\" id=\"webform-component-civicrm-1-contact-1-email-email\">\n  <label for=\"edit-submitted-civicrm-1-contact-1-email-email\" class=\"control-label\">Email <\/label><br \/>\n <input class=\"email form-text form-email\" type=\"email\" id=\"edit-submitted-civicrm-1-contact-1-email-email\" name=\"submitted[civicrm_1_contact_1_email_email]\" size=\"20\"\/>\n<\/div>\n<div class=\"form-item webform-component webform-component-radios\" id=\"webform-component-civicrm-1-contact-1-cg2-custom-12\">\n  <label for=\"edit-submitted-civicrm-1-contact-1-cg2-custom-12\" class=\"control-label\">Is this Organization a Nonprofit? <\/label><\/p>\n<div id=\"edit-submitted-civicrm-1-contact-1-cg2-custom-12\" class=\"form-radios\">\n<div class=\"form-type-radio form-item-submitted-civicrm-1-contact-1-cg2-custom-12 form-item\">\n  <label class=\"option radio\" for=\"edit-submitted-civicrm-1-contact-1-cg2-custom-12-1\"> <input type=\"radio\" id=\"edit-submitted-civicrm-1-contact-1-cg2-custom-12-1\" name=\"submitted[civicrm_1_contact_1_cg2_custom_12]\" value=\"1\" class=\"form-radio\"\/>Yes <\/label>\n<\/div>\n<div class=\"form-type-radio form-item-submitted-civicrm-1-contact-1-cg2-custom-12 form-item\">\n  <label class=\"option radio\" for=\"edit-submitted-civicrm-1-contact-1-cg2-custom-12-2\"> <input type=\"radio\" id=\"edit-submitted-civicrm-1-contact-1-cg2-custom-12-2\" name=\"submitted[civicrm_1_contact_1_cg2_custom_12]\" value=\"0\" class=\"form-radio\"\/>No <\/label>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"form-item webform-component webform-component-checkboxes\" id=\"webform-component-civicrm-1-contact-1-cg2-custom-11\">\n  <label for=\"edit-submitted-civicrm-1-contact-1-cg2-custom-11\" class=\"control-label\">Organization Type <\/label><\/p>\n<div class=\"description\">(Check all that apply)<\/div>\n<div id=\"edit-submitted-civicrm-1-contact-1-cg2-custom-11\" class=\"form-checkboxes\">\n<div class=\"form-type-checkbox form-item-submitted-civicrm-1-contact-1-cg2-custom-11-Science form-item\">\n  <label class=\"option checkbox control-label\" for=\"edit-submitted-civicrm-1-contact-1-cg2-custom-11-1\"> <input type=\"checkbox\" id=\"edit-submitted-civicrm-1-contact-1-cg2-custom-11-1\" name=\"submitted[civicrm_1_contact_1_cg2_custom_11][Science]\" value=\"Science\" class=\"form-checkbox\"\/>Science <\/label>\n<\/div>\n<div class=\"form-type-checkbox form-item-submitted-civicrm-1-contact-1-cg2-custom-11-Advocacy form-item\">\n  <label class=\"option checkbox control-label\" for=\"edit-submitted-civicrm-1-contact-1-cg2-custom-11-2\"> <input type=\"checkbox\" id=\"edit-submitted-civicrm-1-contact-1-cg2-custom-11-2\" name=\"submitted[civicrm_1_contact_1_cg2_custom_11][Advocacy]\" value=\"Advocacy\" class=\"form-checkbox\"\/>Advocacy <\/label>\n<\/div>\n<div class=\"form-type-checkbox form-item-submitted-civicrm-1-contact-1-cg2-custom-11-Medical form-item\">\n  <label class=\"option checkbox control-label\" for=\"edit-submitted-civicrm-1-contact-1-cg2-custom-11-3\"> <input type=\"checkbox\" id=\"edit-submitted-civicrm-1-contact-1-cg2-custom-11-3\" name=\"submitted[civicrm_1_contact_1_cg2_custom_11][Medical]\" value=\"Medical\" class=\"form-checkbox\"\/>Medical <\/label>\n<\/div>\n<div class=\"form-type-checkbox form-item-submitted-civicrm-1-contact-1-cg2-custom-11-Education\/Support form-item\">\n  <label class=\"option checkbox control-label\" for=\"edit-submitted-civicrm-1-contact-1-cg2-custom-11-4\"> <input type=\"checkbox\" id=\"edit-submitted-civicrm-1-contact-1-cg2-custom-11-4\" name=\"submitted[civicrm_1_contact_1_cg2_custom_11][Education\/Support]\" value=\"Education\/Support\" class=\"form-checkbox\"\/>Education\/Support <\/label>\n<\/div>\n<div class=\"form-type-checkbox form-item-submitted-civicrm-1-contact-1-cg2-custom-11-Other form-item\">\n  <label class=\"option checkbox control-label\" for=\"edit-submitted-civicrm-1-contact-1-cg2-custom-11-5\"> <input type=\"checkbox\" id=\"edit-submitted-civicrm-1-contact-1-cg2-custom-11-5\" name=\"submitted[civicrm_1_contact_1_cg2_custom_11][Other]\" value=\"Other\" class=\"form-checkbox\"\/>Other <\/label>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"form-item webform-component webform-component-textfield\" id=\"webform-component-civicrm-1-contact-1-cg2-custom-17\">\n  <label for=\"edit-submitted-civicrm-1-contact-1-cg2-custom-17\" class=\"control-label\">Other Organization Type <\/label><br \/>\n <input type=\"text\" id=\"edit-submitted-civicrm-1-contact-1-cg2-custom-17\" name=\"submitted[civicrm_1_contact_1_cg2_custom_17]\" value=\"\" size=\"20\" maxlength=\"128\" class=\"form-text\"\/>\n<\/div>\n<div class=\"form-item webform-component webform-component-select\" id=\"webform-component-civicrm-1-contact-1-cg2-custom-13\">\n  <label for=\"edit-submitted-civicrm-1-contact-1-cg2-custom-13\" class=\"control-label\">Primary Disease Focus <\/label><br \/>\n <select id=\"edit-submitted-civicrm-1-contact-1-cg2-custom-13\" name=\"submitted[civicrm_1_contact_1_cg2_custom_13]\" class=\"form-select\"><option value=\"\" selected=\"selected\">&#8211; None &#8211;<\/option><option value=\"Angelman Syndrome\">Angelman Syndrome<\/option><option value=\"Ataxia-telangiectasia\">Ataxia-telangiectasia<\/option><option value=\"Autism Spectrum Disorder\">Autism Spectrum Disorder<\/option><option value=\"Brain Trauma\">Brain Trauma<\/option><option value=\"Canavan's Disease\">Canavan&#8217;s Disease<\/option><option value=\"Cerebral Palsy\">Cerebral Palsy<\/option><option value=\"Down Syndrome\">Down Syndrome<\/option><option value=\"Epilepsy\">Epilepsy<\/option><option value=\"Hurler's Syndrome\">Hurler&#8217;s Syndrome<\/option><option value=\"Hydrocephalus\">Hydrocephalus<\/option><option value=\"Hypoxic Injury\">Hypoxic Injury<\/option><option value=\"Intraventricular Hemorrhage\">Intraventricular Hemorrhage<\/option><option value=\"Krabbe's Disease\">Krabbe&#8217;s Disease<\/option><option value=\"Leukodystrophy\">Leukodystrophy<\/option><option value=\"Pervasive Developmental Disorder\">Pervasive Developmental Disorder<\/option><option value=\"Rett Syndrome\">Rett Syndrome<\/option><option value=\"Sandhoff Disease\">Sandhoff Disease<\/option><option value=\"Sanfillipo Syndrome\">Sanfillipo Syndrome<\/option><option value=\"Spinal Muscular Atrophy\">Spinal Muscular Atrophy<\/option><option value=\"Stroke, Pediatric or In-utero\">Stroke, Pediatric or In-utero<\/option><option value=\"Tay-Sachs Disease\">Tay-Sachs Disease<\/option><option value=\"Undiagnosed Brain Condition\">Undiagnosed Brain Condition<\/option><option value=\"Other\">Other\u2026 Please Describe<\/option><\/select>\n<\/div>\n<div class=\"form-item webform-component webform-component-textfield\" id=\"webform-component-civicrm-1-contact-1-cg2-custom-14\">\n  <label for=\"edit-submitted-civicrm-1-contact-1-cg2-custom-14\" class=\"control-label\">Other Disease Focus <\/label><br \/>\n <input type=\"text\" id=\"edit-submitted-civicrm-1-contact-1-cg2-custom-14\" name=\"submitted[civicrm_1_contact_1_cg2_custom_14]\" value=\"\" size=\"20\" maxlength=\"128\" class=\"form-text\"\/>\n<\/div>\n<div class=\"form-item webform-component webform-component-textfield\" id=\"webform-component-civicrm-1-contact-1-cg2-custom-15\">\n  <label for=\"edit-submitted-civicrm-1-contact-1-cg2-custom-15\" class=\"control-label\">Primary Project\/Program\/Activity <\/label><br \/>\n <input type=\"text\" id=\"edit-submitted-civicrm-1-contact-1-cg2-custom-15\" name=\"submitted[civicrm_1_contact_1_cg2_custom_15]\" value=\"\" size=\"20\" maxlength=\"128\" class=\"form-text\"\/>\n<\/div>\n<div class=\"form-item webform-component webform-component-textfield\" id=\"webform-component-civicrm-1-contact-1-cg2-custom-16\">\n  <label for=\"edit-submitted-civicrm-1-contact-1-cg2-custom-16\" class=\"control-label\">Is there a common link to the mission of Pediatric Brain Foundation? <\/label><br \/>\n <input type=\"text\" id=\"edit-submitted-civicrm-1-contact-1-cg2-custom-16\" name=\"submitted[civicrm_1_contact_1_cg2_custom_16]\" value=\"\" size=\"20\" maxlength=\"128\" class=\"form-text\"\/>\n<\/div>\n<div class=\"form-item webform-component webform-component-textarea\" id=\"webform-component-additional-notes-comments-questions\">\n  <label for=\"edit-submitted-additional-notes-comments-questions\" class=\"control-label\">Additional Notes\/Comments\/Questions <\/label><\/p>\n<div class=\"form-textarea-wrapper\"><textarea name=\"submitted[additional_notes_comments_questions]\" id=\"edit-submitted-additional-notes-comments-questions\" cols=\"60\" rows=\"5\" class=\"form-textarea\"><\/textarea><\/div>\n<\/div>\n<p><input type=\"hidden\" 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