Profile:Edit Registration Form

gistfile1.html

{exp:profile:register 
  include_jquery='no' 
  safecracker_head='no' 
  return='notifications/member/registration-success' 
  group_id='5' 
  class='member-register' 
  json='yes' 
  rules:age='required' 
  rules:email='required|valid_email' 
  rules:member_first_name='required' 
  rules:member_last_name='required' 
  rules:screen_name='required' 
  rules:password='required' 
  rules:terms='required' 
  activation_return='profile/registration-complete'
}
  <div class="fieldgroup form-select register age">
    <label for="age">Your Age<span>*</span></label>
    <div>
        <select name="member_age_range" id="age" class="required">
            <option value="">Select your age range</option>
            <option value="18-29">18-29</option>
            <option value="30-39">30-39</option>
            <option value="40-49">40-49</option>
            <option value="50-59">50-59</option>
            <option value="60-69">60-69</option>
            <option value="70 or Over">70 or Over</option>
        </select>
        <p class="small">You must be 18 or over to register.</p>
    </div>
  </div><!--/.row.form-select-->

  <fieldset class="display">
    <div class="fieldgroup five columns">
      <label for="first-name">First Name<span>*</span></label>
      <input type="text" name="member_first_name" id="first-name" class="required">
    </div><!--/.five-columns-->

    <div class="fieldgroup five columns">
      <label for="last-name">Last Name<span>*</span></label>
      <input type="text" name="member_last_name" id="last-name" class="required">
    </div><!--/.five.columns-->

    <div class="fieldgroup ten columns">
      <label for="address-1">Address 1</label>
      <input type="text" name="member_address" id="address-1">
    </div><!--/.ten.columns-->

    <div class="fieldgroup ten columns">
      <label for="address-2">Address 2</label>
      <input type="text" name="member_address2" id="address-2">
    </div><!--/.ten.columns-->

    <div class="clearfix">
        <div class="fieldgroup five columns">
          <label for="city">City</label>
          <input type="text" name="member_city" id="city">
        </div><!--/.five.columns-->

        <div class="fieldgroup five columns">
          <label for="state">State</label>
          <select name="member_state" id="state"> 
            <!-- States List -->
          </select>
        </div><!--/.five.columns-->
    </div><!--/.clearfix-->

    <div class="fieldgroup five columns">
      <label for="zip">Zip Code</label>
      <input type="text" name="member_zip" id="zip">
    </div><!--/.five.columns-->
  </fieldset>

  <fieldset>
    <div class="fieldgroup">
      <label for="screen-name">Screen Name<span>*</span></label>
      <input type="text" name="screen_name" id="screen-name" class="required">
      <p class="small">This is the name that will show when you share your comments.</p>
    </div>

    <div class="fieldgroup">
      <label for="member-email">Your Email<span>*</span></label>
      <input type="email" name="email" id="member-email" class="email required">
    </div>

    <div class="fieldgroup">
      <label for="email-confirm">Repeat Email<span>*</span></label>
      <input type="email" name="email_confirm" id="email-confirm" class="email required" equalto="#member-email">
    </div>

    <div class="fieldgroup">
      <label for="member-password">Password<span>*</span></label>
      <input type="password" name="password" id="member-password" class="required password">
    </div>

    <div class="fieldgroup">
      <label for="password-confirm">Repeat Password<span>*</span></label>
      <input type="password" name="password_confirm" id="password-confirm" class="required password" equalto="#member-password">
    </div>
  </fieldset>

  <fieldset>
    <div class="fieldgroup inline-checkbox">
      <input type="checkbox" name="terms" id="terms" class="required">
      <label for="terms">I agree to the <a href="/terms-and-conditions" target="_blank" >terms and conditions</a> lorem ipsum...</label>
    </div><!--/.inline-checkbox-->
  </fieldset>

  <input type="submit" value="Register" class="button-alviia">

{/exp:profile:register}