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  1. <!-- Begin MailChimp Signup Form -->
  2. <link href="//cdn-images.mailchimp.com/embedcode/classic-10_7.css" rel="nofollow" type="text/css">
  3. <style type="text/css">
  4. #mc_embed_signup {
  5. clear: left;
  6. font: 12px, lato;
  7. }
  8.  
  9. /* Add your own MailChimp form style overrides in your site stylesheet or in this style block.
  10. We recommend moving this block and the preceding CSS link to the HEAD of your HTML file. */
  11. </style>
  12. <div id="mc_embed_signup">
  13. <form action="//babyboxcanada.us12.list-manage.com/subscribe/post?u=f73f1a97a847d57951c2a7348&id=011e0a2840"
  14. method="post" id="mc-embedded-subscribe-form" name="mc-embedded-subscribe-form" class="validate"
  15. target="_blank" novalidate>
  16. <div id="mc_embed_signup_scroll">
  17. <h5 style="color:#15a4d6; padding-bottom:0px; font-weight:300; 22px;">Personal Information</h5>
  18. <div style="-20px! important;" class="mc-field-group">
  19.  
  20. <input id="mce-FNAME" type="text" name="FNAME" class="required" value="" placeholder="First name*"/>
  21. </div>
  22. <div style="-20px! important;" class="mc-field-group">
  23. <input id="mce-LNAME" type="text" name="LNAME" class="required" value="" placeholder="Last name*"/>
  24.  
  25. </div>
  26. <div style="-20px! important;" class="mc-field-group">
  27. <input id="mce-EMAIL" type="email" name="EMAIL" class="required" value="" placeholder="Email*"/>
  28. </div>
  29. <div class="mc-field-group">
  30. <label for="mce-DUEDATE-month"><h5
  31. style="color:#15a4d6; padding-bottom:0px; font-weight:300; 22px;10px;">When is the baby due to
  32. arrive?*</h5>
  33. </label>
  34. <div class="datefield">
  35. <span class="subfield dayfield"><input class="datepart required" type="text" pattern="[0-9]*"
  36. value="" placeholder="DD" size="2" maxlength="2"
  37. name="DUEDATE[day]" id="mce-DUEDATE-day"></span> /
  38. <span class="subfield monthfield"><input class="datepart required" type="text" pattern="[0-9]*"
  39. value="" placeholder="MM" size="2" maxlength="2"
  40. name="DUEDATE[month]" id="mce-DUEDATE-month"></span> /
  41. <span class="subfield yearfield"><input class="datepart required" type="text" pattern="[0-9]*"
  42. value="" placeholder="YYYY" size="4" maxlength="4"
  43. name="DUEDATE[year]" id="mce-DUEDATE-year"></span>
  44. </div>
  45. </div>
  46. <div class="mc-field-group">
  47. <label for="mce-GENDER"><h5 style="color:#15a4d6; padding-bottom:0px; font-weight:300; 22px;0px;">Will
  48. it be a boy or a girl?*</h5>
  49. </label>
  50. <select name="GENDER" class="required" id="mce-GENDER">
  51. <option value=""></option>
  52. <option value="Male">Male</option>
  53. <option value="Female">Female</option>
  54. <option value="Unknown">Unknown</option>
  55.  
  56. </select>
  57. </div>
  58.  
  59.  
  60. <div class="mc-address-group">
  61.  
  62. <div style="-20px! Important; -30px! Important;" class="mc-field-group">
  63.  
  64. <h5 style="color:#15a4d6; padding-bottom:0px; font-weight:300; 22px;">Address</h5>
  65.  
  66. <input type="text" value="" maxlength="70" name="MMERGE15[addr1]" id="mce-MMERGE15-addr1"
  67. class="required" placeholder="Address">
  68. </div>
  69. <div style="-20px! important;" class="mc-field-group">
  70. <input type="text" value="" maxlength="70" name="MMERGE15[addr2]" id="mce-MMERGE15-addr2"
  71. placeholder="Address line 2">
  72. </div>
  73. <div style="-20px! Important;" class="mc-field-group size1of2">
  74.  
  75. <input type="text" value="" maxlength="40" name="MMERGE15[city]" id="mce-MMERGE15-city"
  76. class="required" placeholder="City">
  77. </div>
  78. <div style="-20px! Important;" class="mc-field-group size1of2">
  79.  
  80. <input type="text" value="" maxlength="20" name="MMERGE15[state]" id="mce-MMERGE15-state"
  81. class="required" placeholder="Province">
  82. </div>
  83. <div style="-20px! Important;" class="mc-field-group size1of2">
  84.  
  85. <input type="text" value="" maxlength="10" name="MMERGE15[zip]" id="mce-MMERGE15-zip"
  86. class="required" placeholder="Postal Code">
  87. </div>
  88. <div class="mc-field-group size1of2">
  89. <select name="MMERGE15[country]" id="mce-MMERGE15-country" class="required">
  90. <option value="30" selected>Canada</option>
  91. </select>
  92. </div>
  93. </div>
  94.  
  95.  
  96. <div class="mc-field-group">
  97. <label for="mce-MMERGE8"><h5 style="color:#15a4d6; padding-bottom:0px; font-weight:300; 22px;-10px;">I'm
  98. currently expecting my: </h5></label>
  99. <select name="MMERGE8" class="required" id="mce-MMERGE8">
  100. <option value=""></option>
  101. <option value="1st child">1st child</option>
  102. <option value="2nd child">2nd child</option>
  103. <option value="3rd child">3rd child</option>
  104. <option value="4th child">4th child</option>
  105. <option value="I have lots of kids">I have lots of kids</option>
  106.  
  107. </select>
  108. </div>
  109.  
  110. <div class="mc-field-group">
  111. <label for="mce-MMERGE10"><h5 style="color:#15a4d6; padding-bottom:0px; font-weight:300; 22px;-10px;">
  112. What is your employment position level?* </h5></label>
  113. <select name="MMERGE10" class="required" id="mce-MMERGE10">
  114. <option value=""></option>
  115. <option value="Entry">Entry</option>
  116. <option value="Associate">Associate</option>
  117. <option value="Intermediate">Intermediate</option>
  118. <option value="Senior">Senior</option>
  119. <option value="Advisory">Advisory</option>
  120. <option value="Senior Advisory">Senior Advisory</option>
  121. <option value="Supervisor">Supervisor</option>
  122. <option value="Manager">Manager</option>
  123. <option value="Senior Manager">Senior Manager</option>
  124. <option value="Director">Director</option>
  125. <option value="Senior Director">Senior Director</option>
  126. <option value="Executive">Executive</option>
  127. <option value="Senior Executive">Senior Executive</option>
  128. </select>
  129. </div>
  130.  
  131. <div class="mc-field-group">
  132. <label for="mce-MMERGE11"><h5 style="color:#15a4d6; padding-bottom:0px; font-weight:300; 22px;-10px;">
  133. What is your yearly household income?*</h5></label>
  134. <select name="MMERGE11" class="required" id="mce-MMERGE11">
  135. <option value=""></option>
  136. <option value="Less than $20,000">Less than $20,000</option>
  137. <option value="$20,000 - $34,999">$20,000 - $34,999</option>
  138. <option value="$35,000 - $49,999">$35,000 - $49,999</option>
  139. <option value="$50,000 - $74,999">$50,000 - $74,999</option>
  140. <option value="$75,000 - $99,999">$75,000 - $99,999</option>
  141. <option value="$100,000 - $149,999">$100,000 - $149,999</option>
  142. <option value="$150,000 - $199,999">$150,000 - $199,999</option>
  143. <option value="$200,000 or more">$200,000 or more</option>
  144. </select>
  145. </div>
  146.  
  147. <div class="mc-field-group">
  148. <label for="mce-MMERGE12"><h5 style="color:#15a4d6; padding-bottom:0px; font-weight:300; 22px;-10px;">
  149. How are you planning to feed your newborn?*</h5></label>
  150. <p style="-10px;0px;">Please note that your answers help us in the development of resources</p>
  151. <select name="MMERGE12" class="required" id="mce-MMERGE12">
  152. <option value=""></option>
  153. <option value="I plan to breastfeed exclusively">I plan to breastfeed exclusively</option>
  154. <option value="I plan to breastfeed and pump/express my own milk for bottle feeding">I plan to
  155. breastfeed and pump/express my own milk for bottle feeding
  156. </option>
  157. <option value="For physical/medical reasons, I plan to obtain breastmilk from a third party">For
  158. physical/medical reasons, I plan to obtain breastmilk from a third party
  159. </option>
  160. <option value="For physical/medical reasons, I plan to formula feed">For physical/medical reasons, I
  161. plan to formula feed
  162. </option>
  163. <option value="For ideological/emotional reasons, I plan to formula feed">For ideological/emotional
  164. reasons, I plan to formula feed
  165. </option>
  166. <option value="I plan to combine or supplement breastfeeding with formula">I plan to combine or
  167. supplement breastfeeding with formula
  168. </option>
  169. <option value="I have not decided and am seeking more information">I have not decided and am seeking
  170. more information
  171. </option>
  172.  
  173. </select>
  174. </div>
  175.  
  176. <div class="mc-field-group">
  177. <label for="show_my_phone"><h5 style="color:#15a4d6; padding-bottom:0px; font-weight:300; 22px;-10px;">
  178. Text Text Text</h5></label>
  179. <input type="checkbox" name="show_my_phone" id="show_my_phone" onclick="onTogglePhone(this)" />
  180. </div>
  181.  
  182. <div style="-20px! Important; -30px! Important;" class="mc-field-group phone-wrap">
  183.  
  184. <h5 style="color:#15a4d6; padding-bottom:0px; font-weight:300; 22px;">Phone number</h5>
  185.  
  186. <input type="text" value="" maxlength="70" name="phone_number" id="phone_number"
  187. class="required" placeholder="Address">
  188. </div>
  189.  
  190. <div id="mce-responses" class="clear" value="" placeholder="Province*">
  191. <div class="response" id="mce-error-response" style="display:none"></div>
  192. <div class="response" id="mce-success-response" style="display:none"></div>
  193. </div>
  194.  
  195.  
  196.  
  197. <!-- real people should not fill this in and expect good things - do not remove this or risk from bot signups-->
  198. <div style="position: absolute; left: -5000px;" aria-hidden="true"><input type="text"
  199. name="b_f73f1a97a847d57951c2a7348_011e0a2840"
  200. tabindex="-1" value=""></div>
  201. <div class="clear"><input type="submit" value="Register" name="Subscribe" id="mc-embedded-subscribe"
  202. class="button"></div>
  203. </div>
  204. </form>
  205. </div>
  206.  
  207. <!--End mc_embed_signup-->
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