<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>