embed-code.html

<!--Begin CTCT Sign-Up Form-->
<!-- EFD 1.0.0 [Mon Aug 28 11:09:22 EDT 2017] -->

<div class="ctct-embed-signup">
   <div>
       <span id="success_message" style="display:none;">
           <div style="text-align:center;">
                <h3 class="article--title">
                    Thank you for taking the next step in healing your arthritis. You should receive your video in your email shortly.
                </h3>
            </div>
       </span>
       <form data-id="embedded_signup:form" class="ctct-custom-form Form" name="embedded_signup" method="POST" action="https://visitor2.constantcontact.com/api/signup">

           <p></p>
           <!-- The following code must be included to ensure your sign-up form works properly. -->
            <input data-id="ca:input" type="hidden" name="ca" value="fd342522-1003-4f26-ba37-ae62bf64ef16">
            <input data-id="list:input" type="hidden" name="list" value="2091333883">
            <input data-id="source:input" type="hidden" name="source" value="EFD">
            <input data-id="required:input" type="hidden" name="required" value="list,email,first_name">
            <input data-id="url:input" type="hidden" name="url" value="">

            <div class="clear mc-field-group">
                <p data-id="Email Address:p" >

                    <label data-id="Email Address:label" data-name="email" class="ctct-form-required"></label>   <input data-id="Email Address:input" type="text" placeholder="Email Address" name="email" value="" maxlength="80">
                </p>
            </div>

            <div class="clear mc-field-group">
                <p data-id="First Name:p" >
                    <label data-id="First Name:label" data-name="first_name" class="ctct-form-required"></label> <input data-id="First Name:input" type="text" name="first_name" placeholder="First Name" value="" maxlength="50">
                </p>
            </div>

            <div class="clear mc-field-group">
                <button type="submit" class="Button js-btn button ctct-button Button--block Button-secondary" data-enabled="enabled">Send Me The Free Video!</button>
            </div>


            <!--
            <p class="ctct-form-footer">By submitting this form, you are granting: Blum Center for Health, 34 Rye Ridge Plaza, Rye Brook, New York, 10573, United States, http://www.blumcenterforhealth.compermission to email you. You may unsubscribe via the link found at the bottom of every email.  (See our <a href="http://www.constantcontact.com/legal/privacy-statement" target="_blank">Email Privacy Policy</a> for details.) Emails are serviced by Constant Contact.</p>
            -->
       </form>
   </div>
</div>
<script type='text/javascript'>
   var localizedErrMap = {};
   localizedErrMap['required'] = 'This field is required.';
   localizedErrMap['ca'] = 'An unexpected error occurred while attempting to send email.';
   localizedErrMap['email'] = 'Please enter your email address in [email protected] format.';
   localizedErrMap['birthday'] = 'Please enter birthday in MM/DD format.';
   localizedErrMap['anniversary'] = 'Please enter anniversary in MM/DD/YYYY format.';
   localizedErrMap['custom_date'] = 'Please enter this date in MM/DD/YYYY format.';
   localizedErrMap['list'] = 'Please select at least one email list.';
   localizedErrMap['generic'] = 'This field is invalid.';
   localizedErrMap['shared'] = 'Sorry, we could not complete your sign-up. Please contact us to resolve this.';
   localizedErrMap['state_mismatch'] = 'Mismatched State/Province and Country.';
   localizedErrMap['state_province'] = 'Select a state/province';
   localizedErrMap['selectcountry'] = 'Select a country';
   var postURL = 'https://visitor2.constantcontact.com/api/signup';
</script>
<script type='text/javascript' src='https://static.ctctcdn.com/h/contacts-embedded-signup-assets/1.0.2/js/signup-form.js'></script>
<!--End CTCT Sign-Up Form-->