API tools faq
paste
Advertisement
Guest User

registration page feb 13 modification no checkboxes

a guest
Feb 14th, 2017
92
0
Never
Add comment
Not a member of Pastebin yet? Sign Up, it unlocks many cool features!
text 11.36 KB | None | 0 0
raw download clone embed print report
  1. <!-- Begin MailChimp Signup Form -->
  2. <link href="//cdn-images.mailchimp.com/embedcode/classic-10_7.css" rel="stylesheet" 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="margin-bottom:-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="margin-bottom:-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="margin-bottom:-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; margin-top: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;margin-top:10px;">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. <h5 style="color:#15a4d6; padding-bottom:0px; margin-top:0px; font-weight:300; 22px;">Address</h5>
  61.  
  62. <div style="margin-bottom:-20px! Important;" class="mc-field-group" >
  63.  
  64. <input type="text" value="" name="ADDRESS1" class="" id="mce-ADDRESS1" placeholder="Street Address*">
  65. </div>
  66. <div style="margin-bottom:-20px! Important;" class="mc-field-group">
  67. <input type="text" value="" name="ADDRESS2" class="" id="mce-ADDRESS2" placeholder="Address line 2">
  68. </div>
  69.  
  70. <div style="margin-bottom:-20px! Important;" class="mc-field-group size1of2">
  71. <input type="text" value="" name="CITY" class="" id="mce-CITY" placeholder="City*">
  72. </div>
  73. <div style="margin-bottom:-20px! Important;" class="mc-field-group size1of2">
  74.  
  75. <input type="text" value="" name="POSTALCODE" class="" id="mce-POSTALCODE" placeholder="Postal Code*">
  76. </div>
  77. <div class="mc-field-group size1of2">
  78.  
  79. <select name="PROVINCE" class="" id="mce-PROVINCE" >
  80. <option value="">Province*</option>
  81. <option value="Ontario">Ontario</option>
  82. <option value="Alberta">Alberta</option>
  83. <option value="British Columbia">British Columbia</option>
  84. <option value="Manitoba">Manitoba</option>
  85. <option value="New Brunswick">New Brunswick</option>
  86. <option value="Newfoundland &amp; Labrador">Newfoundland &amp; Labrador</option>
  87. <option value="Northwest Territories">Northwest Territories</option>
  88. <option value="Nova Scotia">Nova Scotia</option>
  89. <option value="Nunavut">Nunavut</option>
  90. <option value="Prince Edward Island">Prince Edward Island</option>
  91. <option value="Quebec">Quebec</option>
  92. <option value="Saskatchewan">Saskatchewan</option>
  93. <option value="Yukon">Yukon</option>
  94.  
  95. </select>
  96. </div>
  97.  
  98. <div class="mc-field-group size1of2">
  99. <select name="MMERGE18[country]" class="" id="mce-MMERGE18-country" class="required">
  100. <option value="Canada" selected>Canada</option>
  101. </select>
  102. </div>
  103.  
  104.  
  105.  
  106.  
  107. <div class="mc-field-group">
  108. <label for="mce-MMERGE8"><h5 style="color:#15a4d6; padding-bottom:0px; font-weight:300; 22px;margin-top:-10px;">I'm
  109. currently expecting my: </h5></label>
  110. <select name="MMERGE8" class="required" id="mce-MMERGE8">
  111. <option value=""></option>
  112. <option value="1st child">1st child</option>
  113. <option value="2nd child">2nd child</option>
  114. <option value="3rd child">3rd child</option>
  115. <option value="4th child">4th child</option>
  116. <option value="I have lots of kids">I have lots of kids</option>
  117.  
  118. </select>
  119. </div>
  120.  
  121. <div class="mc-field-group">
  122. <label for="mce-MMERGE10"><h5 style="color:#15a4d6; padding-bottom:0px; font-weight:300; 22px;margin-top:-10px;">
  123. What is your employment position level?* </h5></label>
  124. <select name="MMERGE10" class="required" id="mce-MMERGE10">
  125. <option value=""></option>
  126. <option value="Entry">Entry</option>
  127. <option value="Associate">Associate</option>
  128. <option value="Intermediate">Intermediate</option>
  129. <option value="Senior">Senior</option>
  130. <option value="Advisory">Advisory</option>
  131. <option value="Senior Advisory">Senior Advisory</option>
  132. <option value="Supervisor">Supervisor</option>
  133. <option value="Manager">Manager</option>
  134. <option value="Senior Manager">Senior Manager</option>
  135. <option value="Director">Director</option>
  136. <option value="Senior Director">Senior Director</option>
  137. <option value="Executive">Executive</option>
  138. <option value="Senior Executive">Senior Executive</option>
  139.  
  140. </select>
  141. </div>
  142.  
  143. <div class="mc-field-group">
  144. <label for="mce-MMERGE11"><h5 style="color:#15a4d6; padding-bottom:0px; font-weight:300; 22px;margin-top:-10px;">
  145. What is your yearly household income?*</h5></label>
  146. <select name="MMERGE11" class="required" id="mce-MMERGE11">
  147. <option value=""></option>
  148. <option value="Less than $20,000">Less than $20,000</option>
  149. <option value="$20,000 - $34,999">$20,000 - $34,999</option>
  150. <option value="$35,000 - $49,999">$35,000 - $49,999</option>
  151. <option value="$50,000 - $74,999">$50,000 - $74,999</option>
  152. <option value="$75,000 - $99,999">$75,000 - $99,999</option>
  153. <option value="$100,000 - $149,999">$100,000 - $149,999</option>
  154. <option value="$150,000 - $199,999">$150,000 - $199,999</option>
  155. <option value="$200,000 or more">$200,000 or more</option>
  156.  
  157. </select>
  158. </div>
  159.  
  160. <div class="mc-field-group">
  161. <label for="mce-MMERGE12"><h5 style="color:#15a4d6; padding-bottom:0px; font-weight:300; 22px;margin-top:-10px;">
  162. How are you planning to feed your newborn?*</h5></label>
  163. <p style="margin-top:-10px;0px;">Please note that your answers help us in the development of resources</p>
  164. <select name="MMERGE12" class="required" id="mce-MMERGE12">
  165. <option value=""></option>
  166. <option value="I plan to breastfeed exclusively">I plan to breastfeed exclusively</option>
  167. <option value="I plan to breastfeed and pump/express my own milk for bottle feeding">I plan to
  168. breastfeed and pump/express my own milk for bottle feeding
  169. </option>
  170. <option value="For physical/medical reasons, I plan to obtain breastmilk from a third party">For
  171. physical/medical reasons, I plan to obtain breastmilk from a third party
  172. </option>
  173. <option value="For physical/medical reasons, I plan to formula feed">For physical/medical reasons, I
  174. plan to formula feed
  175. </option>
  176. <option value="For ideological/emotional reasons, I plan to formula feed">For ideological/emotional
  177. reasons, I plan to formula feed
  178. </option>
  179. <option value="I plan to combine or supplement breastfeeding with formula">I plan to combine or
  180. supplement breastfeeding with formula
  181. </option>
  182. <option value="I have not decided and am seeking more information">I have not decided and am seeking
  183. more information
  184. </option>
  185.  
  186. </select>
  187. </div>
  188.  
  189.  
  190.  
  191.  
  192.  
  193. <div id="mce-responses" class="clear" value="" placeholder="Province*">
  194. <div class="response" id="mce-error-response" style="display:none"></div>
  195. <div class="response" id="mce-success-response" style="display:none"></div>
  196. </div>
  197.  
  198.  
  199.  
  200. <!-- real people should not fill this in and expect good things - do not remove this or risk from bot signups-->
  201. <div style="position: absolute; left: -5000px;" aria-hidden="true"><input type="text"
  202. name="b_f73f1a97a847d57951c2a7348_011e0a2840"
  203. tabindex="-1" value=""></div>
  204. <div class="clear"><input type="submit" value="Register" name="Subscribe" id="mc-embedded-subscribe"
  205. class="button"></div>
  206. </div>
  207. </form>
  208. </div>
Advertisement
Add Comment
Please, Sign In to add comment
Advertisement
Public Pastes
Advertisement
We use cookies for various purposes including analytics. By continuing to use Pastebin, you agree to our use of cookies as described in the Cookies Policy.  OK, I Understand
Not a member of Pastebin yet?
Sign Up, it unlocks many cool features!