<form action=“{{ site.data.forms.action }}” method=“post” id=“mc-embedded-subscribe-form” name=“mc-embedded-subscribe-form” class=“validate” target=“_blank” novalidate>
<div class="form__block"> <h2 class="form--title">{{ site.data.forms[page.env].header }}</h2> <p class="form--strap">{{ site.data.forms[page.env].strapline }}</p> {% for item in site.data.forms[page.env].inputs %} <div class="form__elem {{ item.type }}__elem mc--{{ item.width }} mc-field-group {% if item.type == 'select' OR item.type == 'radio' %}input-group{% endif %}"> <label class="form--label {{ item.type }}-label" for="{{ item.id }}"> {{ item.label }} {% if item.required %} <span class="mc-asterisk">*</span> {% endif %} </label> {% if item.type == 'radio' %} <ul> {% for option in item.opts %} <li> <input type="{{ item.type }}" value="{{ option.value }}" name="{{ item.name }}" id="{{ item.id }}-{{ option.id }}" {{ item.autofocus }}> <label for="{{ item.id }}-{{ option.id }}"> {{ option.name }} </label> </li> {% endfor %} </ul> {% endif %} {% if item.type == 'select' %} <select name="{{ item.name }}" class="form--select form--elem {% if item.required %}required {% endif %}" id="{{ item.id }}" {{ item.autofocus }}> {% for option in item.opts %} <option type="{{ item.type }}" value="{{ option.value }}" name="{{ item.name }}"> {{ option.name }} </option> {% endfor %} </select> {% endif %} {% if item.type == 'textarea' %} <textarea rows="4" name="{{ item.name }}" id="{{ item.id }}" class="form--textarea form--elem" {{ item.autofocus }}></textarea> {% endif %} {% if item.type == 'checkbox' %} <label class="form--label {{ item.type }}-label--mod" for="{{ item.id }}"> <p>{{ item.label }}</p> <span class="styled-checkbox__block"> <input type="checkbox" class="styled-checkbox switch" id="{{ item.id }}" name="{{ item.name }}" {{ item.autofocus }} value="{{ item.value }}"> <span class="icon"><span class="icon--elem"></span></span> <span class="no">NO</span> <span class="yes">YES</span> </span> </label> {% endif %} {% if item.type != 'select' and item.type != 'radio' and item.type != 'textarea' and item.type != 'checkbox' %} <input type="{{ item.type }}" value="" {% if item.type == 'tel' %} placeholder="Landline or mobile" pattern="[0-9]{3}-[0-9]{3}-[0-9]{4}" {% endif %} name="{{ item.name }}" class="{% if item.required %}required{% endif %} form--input form--elem" id="{{ item.id }}" {{ item.autofocus }}> {% endif %} </div> {% endfor %} <div id="mergeRow-gdpr" class="mergeRow gdpr-mergeRow content__gdprBlock mc-field-group"> <div class="content__gdpr"> <label for="interestgroup_field" class="form--label gdpr--title">What is your prefered method of communication?</label> <fieldset class="mc_fieldset gdprRequired mc-field-group" name="interestgroup_field"> {% for item in site.data.forms[page.env].gdpr %} <label class="mc--{{ item.width }} form--label {{ item.type }}-label--mod checkbox subfield" for="{{ item.id }}"> <p>{{ item.label }}</p> <span class="styled-checkbox__block"> <input type="checkbox" class="styled-checkbox switch av-checkbox gdpr" id="{{ item.id }}" value="Y" name="{{ item.name }}"> <span class="icon"><span class="icon--elem"></span></span> <span class="no">NO</span> <span class="yes">YES</span> </span> </label> {% endfor %} </fieldset> <p class="content__gdprLegal"> You can unsubscribe at any time by clicking the link at the bottom of our emails. For information about our privacy practices, click <a href="/privacy-policy/">here</a>. </p> <p class="content__gdprLegal"> We use Mailchimp as our marketing platform. By clicking below, you acknowledge that your information will be transferred to Mailchimp for processing. Learn more about Mailchimp's privacy practices <a href="https://mailchimp.com/legal/" target="_blank">here.</a> </p> </div> </div> <div class="clear"> <input type="submit" value="Submit" name="subscribe" id="mc-embedded-subscribe" class="button"> </div> <div id="mce-responses" class="clear"> <div class="response" id="mce-error-response" style="display:none"></div> <div class="response" id="mce-success-response" style="display:none"></div> </div> <!-- real people should not fill this in and expect good things - do not remove this or risk form bot signups--> <div style="position: absolute; left: -5000px;" aria-hidden="true"> <input type="text" name="{{ site.data.forms.walk.botspot-name }}" tabindex="-1" value=""> </div> <div class="mc-field-group input-group" style="position: absolute; left: -5000px;" aria-hidden="true"> <select name="USERTYPE" class="required" id="mce-USERTYPE" > {% if page.env == 'walk' %} <option value="PwP" selected></option> {% else %} <option value="Clinician" selected></option> {% endif %} </select> </div> </div> </form> <script type='text/javascript' src='//s3.amazonaws.com/downloads.mailchimp.com/js/mc-validate.js'></script> <script type='text/javascript'> (function($) { window.fnames = new Array(); window.ftypes = new Array(); /* fnames[0] = 'EMAIL'; ftypes[0] = 'email'; fnames[2] = 'FNAME'; ftypes[2] = 'text'; fnames[4] = 'LNAME'; ftypes[4] = 'text'; fnames[6] = 'TEL'; ftypes[6] = 'number'; fnames[3] = 'USERDES'; ftypes[3] = 'dropdown'; fnames[1] = 'USERTYPE'; ftypes[1] = 'dropdown'; fnames[5] = 'MESSAGE'; ftypes[5] = 'text'; */ {% for item in site.data.forms[page.env].inputs %} fnames[{{ forloop.index0 }}] = '{{ item.name }}'; ftypes[{{ forloop.index0 }}] = '{{ item.type }}'; {% if forloop.last == true %} fnames[{{ forloop.index }}] = 'USERTYPE'; ftypes[{{ forloop.index }}] = 'dropdown'; {% endif %} {% endfor %} }(jQuery)); var $mcj = jQuery.noConflict(true); </script>