<input type="hidden" name="item_name"

             value="Conservancy Supporter, {{ supptype|capfirst }}{% if form_id == "renewal" %} Renewal{% endif %}"

             >

      <div class="supporter-form-input">

        {% if form_id == "monthly" %}

        <input type="hidden" name="cmd" value="_xclick-subscriptions">

        <input type="hidden" name="lc" value="US">

        <input type="hidden" name="no_note" value="1">

        <input type="hidden" name="t3" value="M">

        <input type="hidden" name="p3" value="1">

        <input type="hidden" name="src" value="1">

        <input type="hidden" name="srt" value="0">

        <label for="a3">Monthly Amount: </label>

        <div class="input-group">

        $ <input type="number" name="a3" size="5" tabindex="10"

               min="{{ min_amt }}" value="{{ default_amt }}">

        {% else %}

        <input type="hidden" name="cmd" value="_xclick">

        <label for="amount">Amount: </label>

        <div class="input-group">

        $ <input type="number" name="amount" size="5" tabindex="10"

               min="{{ min_amt }}" value="{{ default_amt }}">

        {% endif %}

        <p class="form-error">${{ min_amt|add:partial_amt }} is a minimum for

          Conservancy Supporters.

          <a href="/donate">Donate smaller amounts here</a>.</p>

        </div>

      </div>

      <div class="supporter-form-input">

        <label for="on0">Do you want to receive

          {% if form_id == "renewal" %}

          another

          {% else %}

          a

          {% endif %}

          shirt? </label>

        <div class="input-group">

          <input type="radio" tabindex="20" name="on0" value="wantGiftYes">Yes

          <input type="radio" tabindex="20" checked="checked" name="on0" value="wantGiftNo">No

        </div>

      </div>

      <div class="supporter-form-input t-shirt-size-selector">

        <label for="os0">Shirt size: </label>

        <div class="input-group">

          <select name="os0" tabindex="30">

          </select>

        </div>

      </div>

      <div class="supporter-form-input">

        <label for="publicAck">

          Should we add you to the <a href="/sponsors#supporters">Conservancy Supporters list</a>? </label>

        <div class="input-group">

          <input type="radio" tabindex="40" checked="checked" name="on1" value="publicAckYes">Yes

          <input type="radio" tabindex="40" name="on1" value="publicAckNo">No

        </div>

      </div>

      <div class="supporter-form-input">

        <label for="joinList">Join Conservancy's

          low-traffic announcement list? </label>

        <div class="input-group">

          <input type="radio" tabindex="50" checked="checked" name="os1" value="joinListYes">Yes

          <input type="radio" tabindex="50" name="os1" value="joinListNo">No

        </div>

      </div>

    </div>

    <div class="supporter-form-submit">

      <input type="image" name="submit" tabindex="60"

             src="/img/supporter-payment-button-{{ form_id }}.png"

             height="81" width="188" border="0"

             alt="{{ verb|capfirst }} as {{ article }} {{ supptype|capfirst }} Supporter Now!">

      <p>This button will send you to PayPal's site to select a payment

        method and finish this process.  Please double-check your selections

        first.</p>

    </div>

  </form>

</div>

{% endwith %}