{"id":1065,"date":"2014-08-19T15:47:59","date_gmt":"2014-08-19T05:47:59","guid":{"rendered":"https:\/\/fireshapercom.makemywebsite.au\/westwood\/blog\/fire-shapers-health-questionnaire\/"},"modified":"2014-12-30T16:40:17","modified_gmt":"2014-12-30T06:40:17","slug":"firebody","status":"publish","type":"post","link":"https:\/\/fireshapercom.makemywebsite.au\/westwood\/blog\/firebody\/","title":{"rendered":"Fire Shapers Health Questionnaire"},"content":{"rendered":"<p><!-- Begin MailChimp Signup Form --><\/p>\n<link href=\"\/\/cdn-images.mailchimp.com\/embedcode\/classic-081711.css\" rel=\"stylesheet\" type=\"text\/css\" \/>\n<style type=\"text\/css\"><!--\n#mc_embed_signup{background:#fff; clear:left; font:14px Helvetica,Arial,sans-serif;  width:579px;} \/* Add your own MailChimp form style overrides in your site stylesheet or in this style block. We recommend moving this block and the preceding CSS link to the HEAD of your HTML file. *\/\n--><\/style>\n<div id=\"mc_embed_signup\">\n<form class=\"validate\" id=\"mc-embedded-subscribe-form\" action=\"\/\/fireshaper.us5.list-manage.com\/subscribe\/post?u=eeb27120dce34fe0aef06968b&amp;id=0737f1d2a0\" method=\"post\" name=\"mc-embedded-subscribe-form\" novalidate=\"\" target=\"_blank\">\n<h2>Complete the questionnaire to a healthier you&#8230;<\/h2>\n<div class=\"indicates-required\"><span class=\"asterisk\">*<\/span> indicates required<\/div>\n<div class=\"mc-field-group\"><label for=\"mce-EMAIL\">Best Email Address <span class=\"asterisk\">*<\/span><br \/>\n<\/label><br \/>\n<input class=\"required email\" id=\"mce-EMAIL\" type=\"email\" name=\"EMAIL\" value=\"\" \/><\/div>\n<div class=\"mc-field-group\"><label for=\"mce-FNAME\">First Name <span class=\"asterisk\">*<\/span><br \/>\n<\/label><br \/>\n<input class=\"required\" id=\"mce-FNAME\" type=\"text\" name=\"FNAME\" value=\"\" \/><\/div>\n<div class=\"mc-field-group\"><label for=\"mce-MMERGE5\">Mobile Number <span class=\"asterisk\">*<\/span><br \/>\n<\/label><br \/>\n<input class=\"required\" id=\"mce-MMERGE5\" type=\"text\" name=\"MMERGE5\" value=\"\" \/><\/div>\n<div class=\"mc-field-group\"><label for=\"mce-MMERGE4\">Country <span class=\"asterisk\">*<\/span><br \/>\n<\/label><br \/>\n<select class=\"required\" id=\"mce-MMERGE4\" name=\"MMERGE4\"><option value=\"\"><\/option><option value=\"United States of America\">United States of America<\/option><option value=\"Aaland Islands\">Aaland Islands<\/option><option value=\"Afghanistan\">Afghanistan<\/option><option value=\"Albania\">Albania<\/option><option value=\"Algeria\">Algeria<\/option><option value=\"American Samoa\">American Samoa<\/option><option value=\"Andorra\">Andorra<\/option><option value=\"Angola\">Angola<\/option><option value=\"Anguilla\">Anguilla<\/option><option value=\"Antarctica\">Antarctica<\/option><option value=\"Antigua And Barbuda\">Antigua And Barbuda<\/option><option value=\"Argentina\">Argentina<\/option><option value=\"Armenia\">Armenia<\/option><option value=\"Aruba\">Aruba<\/option><option value=\"Australia\">Australia<\/option><option value=\"Austria\">Austria<\/option><option value=\"Azerbaijan\">Azerbaijan<\/option><option value=\"Bahamas\">Bahamas<\/option><option value=\"Bahrain\">Bahrain<\/option><option value=\"Bangladesh\">Bangladesh<\/option><option value=\"Barbados\">Barbados<\/option><option value=\"Belarus\">Belarus<\/option><option value=\"Belgium\">Belgium<\/option><option value=\"Belize\">Belize<\/option><option value=\"Benin\">Benin<\/option><option value=\"Bermuda\">Bermuda<\/option><option value=\"Bhutan\">Bhutan<\/option><option value=\"Bolivia\">Bolivia<\/option><option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option><option value=\"Botswana\">Botswana<\/option><option value=\"Bouvet Island\">Bouvet Island<\/option><option value=\"Brazil\">Brazil<\/option><option value=\"British Indian Ocean Territory\">British Indian Ocean Territory<\/option><option value=\"Brunei Darussalam\">Brunei Darussalam<\/option><option value=\"Bulgaria\">Bulgaria<\/option><option value=\"Burkina Faso\">Burkina Faso<\/option><option value=\"Burundi\">Burundi<\/option><option value=\"Cambodia\">Cambodia<\/option><option value=\"Cameroon\">Cameroon<\/option><option value=\"Canada\">Canada<\/option><option value=\"Cape Verde\">Cape Verde<\/option><option value=\"Cayman Islands\">Cayman Islands<\/option><option value=\"Central African Republic\">Central African Republic<\/option><option value=\"Chad\">Chad<\/option><option value=\"Chile\">Chile<\/option><option value=\"China\">China<\/option><option value=\"Christmas Island\">Christmas Island<\/option><option value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option value=\"Colombia\">Colombia<\/option><option value=\"Comoros\">Comoros<\/option><option value=\"Congo\">Congo<\/option><option value=\"Cook Islands\">Cook Islands<\/option><option value=\"Costa Rica\">Costa Rica<\/option><option value=\"Cote D'Ivoire\">Cote D&#8217;Ivoire<\/option><option value=\"Croatia\">Croatia<\/option><option value=\"Cuba\">Cuba<\/option><option value=\"Curacao\">Curacao<\/option><option value=\"Cyprus\">Cyprus<\/option><option value=\"Czech Republic\">Czech Republic<\/option><option value=\"Democratic Republic of the Congo\">Democratic Republic of the Congo<\/option><option value=\"Denmark\">Denmark<\/option><option value=\"Djibouti\">Djibouti<\/option><option value=\"Dominica\">Dominica<\/option><option value=\"Dominican Republic\">Dominican Republic<\/option><option value=\"East Timor\">East Timor<\/option><option value=\"Ecuador\">Ecuador<\/option><option value=\"Egypt\">Egypt<\/option><option value=\"El Salvador\">El Salvador<\/option><option value=\"Equatorial Guinea\">Equatorial Guinea<\/option><option value=\"Eritrea\">Eritrea<\/option><option value=\"Estonia\">Estonia<\/option><option value=\"Ethiopia\">Ethiopia<\/option><option value=\"Falkland Islands\">Falkland Islands<\/option><option value=\"Faroe Islands\">Faroe Islands<\/option><option value=\"Fiji\">Fiji<\/option><option value=\"Finland\">Finland<\/option><option value=\"France\">France<\/option><option value=\"French Guiana\">French Guiana<\/option><option value=\"French Polynesia\">French Polynesia<\/option><option value=\"French Southern Territories\">French Southern Territories<\/option><option value=\"Gabon\">Gabon<\/option><option value=\"Gambia\">Gambia<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Germany\">Germany<\/option><option value=\"Ghana\">Ghana<\/option><option value=\"Gibraltar\">Gibraltar<\/option><option value=\"Greece\">Greece<\/option><option value=\"Greenland\">Greenland<\/option><option value=\"Grenada\">Grenada<\/option><option value=\"Guadeloupe\">Guadeloupe<\/option><option value=\"Guam\">Guam<\/option><option value=\"Guatemala\">Guatemala<\/option><option value=\"Guernsey\">Guernsey<\/option><option value=\"Guinea\">Guinea<\/option><option value=\"Guinea-Bissau\">Guinea-Bissau<\/option><option value=\"Guyana\">Guyana<\/option><option value=\"Haiti\">Haiti<\/option><option value=\"Heard and Mc Donald Islands\">Heard and Mc Donald Islands<\/option><option value=\"Honduras\">Honduras<\/option><option value=\"Hong Kong\">Hong Kong<\/option><option value=\"Hungary\">Hungary<\/option><option value=\"Iceland\">Iceland<\/option><option value=\"India\">India<\/option><option value=\"Indonesia\">Indonesia<\/option><option value=\"Iran\">Iran<\/option><option value=\"Iraq\">Iraq<\/option><option value=\"Ireland\">Ireland<\/option><option value=\"Isle of Man\">Isle of Man<\/option><option value=\"Israel\">Israel<\/option><option value=\"Italy\">Italy<\/option><option value=\"Jamaica\">Jamaica<\/option><option value=\"Japan\">Japan<\/option><option value=\"Jersey  (Channel Islands)\">Jersey (Channel Islands)<\/option><option value=\"Jordan\">Jordan<\/option><option value=\"Kazakhstan\">Kazakhstan<\/option><option value=\"Kenya\">Kenya<\/option><option value=\"Kiribati\">Kiribati<\/option><option value=\"Kuwait\">Kuwait<\/option><option value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option value=\"Lao People's Democratic Republic\">Lao People&#8217;s Democratic Republic<\/option><option value=\"Latvia\">Latvia<\/option><option value=\"Lebanon\">Lebanon<\/option><option value=\"Lesotho\">Lesotho<\/option><option value=\"Liberia\">Liberia<\/option><option value=\"Libya\">Libya<\/option><option value=\"Liechtenstein\">Liechtenstein<\/option><option value=\"Lithuania\">Lithuania<\/option><option value=\"Luxembourg\">Luxembourg<\/option><option value=\"Macau\">Macau<\/option><option value=\"Macedonia\">Macedonia<\/option><option value=\"Madagascar\">Madagascar<\/option><option value=\"Malawi\">Malawi<\/option><option value=\"Malaysia\">Malaysia<\/option><option value=\"Maldives\">Maldives<\/option><option value=\"Mali\">Mali<\/option><option value=\"Malta\">Malta<\/option><option value=\"Marshall Islands\">Marshall Islands<\/option><option value=\"Martinique\">Martinique<\/option><option value=\"Mauritania\">Mauritania<\/option><option value=\"Mauritius\">Mauritius<\/option><option value=\"Mayotte\">Mayotte<\/option><option value=\"Mexico\">Mexico<\/option><option value=\"Micronesia, Federated States of\">Micronesia, Federated States of<\/option><option value=\"Moldova, Republic of\">Moldova, Republic of<\/option><option value=\"Monaco\">Monaco<\/option><option value=\"Mongolia\">Mongolia<\/option><option value=\"Montenegro\">Montenegro<\/option><option value=\"Montserrat\">Montserrat<\/option><option value=\"Morocco\">Morocco<\/option><option value=\"Mozambique\">Mozambique<\/option><option value=\"Myanmar\">Myanmar<\/option><option value=\"Namibia\">Namibia<\/option><option value=\"Nauru\">Nauru<\/option><option value=\"Nepal\">Nepal<\/option><option value=\"Netherlands\">Netherlands<\/option><option value=\"Netherlands Antilles\">Netherlands Antilles<\/option><option value=\"New Caledonia\">New Caledonia<\/option><option value=\"New Zealand\">New Zealand<\/option><option value=\"Nicaragua\">Nicaragua<\/option><option value=\"Niger\">Niger<\/option><option value=\"Nigeria\">Nigeria<\/option><option value=\"Niue\">Niue<\/option><option value=\"Norfolk Island\">Norfolk Island<\/option><option value=\"North Korea\">North Korea<\/option><option value=\"Northern Mariana Islands\">Northern Mariana Islands<\/option><option value=\"Norway\">Norway<\/option><option value=\"Oman\">Oman<\/option><option value=\"Pakistan\">Pakistan<\/option><option value=\"Palau\">Palau<\/option><option value=\"Palestine\">Palestine<\/option><option value=\"Panama\">Panama<\/option><option value=\"Papua New Guinea\">Papua New Guinea<\/option><option value=\"Paraguay\">Paraguay<\/option><option value=\"Peru\">Peru<\/option><option value=\"Philippines\">Philippines<\/option><option value=\"Pitcairn\">Pitcairn<\/option><option value=\"Poland\">Poland<\/option><option value=\"Portugal\">Portugal<\/option><option value=\"Puerto Rico\">Puerto Rico<\/option><option value=\"Qatar\">Qatar<\/option><option value=\"Republic of Kosovo\">Republic of Kosovo<\/option><option value=\"Reunion\">Reunion<\/option><option value=\"Romania\">Romania<\/option><option value=\"Russia\">Russia<\/option><option value=\"Rwanda\">Rwanda<\/option><option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\">Saint Lucia<\/option><option value=\"Saint Vincent and the Grenadines\">Saint Vincent and the Grenadines<\/option><option value=\"Samoa (Independent)\">Samoa (Independent)<\/option><option value=\"San Marino\">San Marino<\/option><option value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option><option value=\"Saudi Arabia\">Saudi Arabia<\/option><option value=\"Senegal\">Senegal<\/option><option value=\"Serbia\">Serbia<\/option><option value=\"Seychelles\">Seychelles<\/option><option value=\"Sierra Leone\">Sierra Leone<\/option><option value=\"Singapore\">Singapore<\/option><option value=\"Sint Maarten\">Sint Maarten<\/option><option value=\"Slovakia\">Slovakia<\/option><option value=\"Slovenia\">Slovenia<\/option><option value=\"Solomon Islands\">Solomon Islands<\/option><option value=\"Somalia\">Somalia<\/option><option value=\"South Africa\">South Africa<\/option><option value=\"South Georgia and the South Sandwich Islands\">South Georgia and the South Sandwich Islands<\/option><option value=\"South Korea\">South Korea<\/option><option value=\"South Sudan\">South Sudan<\/option><option value=\"Spain\">Spain<\/option><option value=\"Sri Lanka\">Sri Lanka<\/option><option value=\"St. Helena\">St. Helena<\/option><option value=\"St. Pierre and Miquelon\">St. Pierre and Miquelon<\/option><option value=\"Sudan\">Sudan<\/option><option value=\"Suriname\">Suriname<\/option><option value=\"Svalbard and Jan Mayen Islands\">Svalbard and Jan Mayen Islands<\/option><option value=\"Swaziland\">Swaziland<\/option><option value=\"Sweden\">Sweden<\/option><option value=\"Switzerland\">Switzerland<\/option><option value=\"Syria\">Syria<\/option><option value=\"Taiwan\">Taiwan<\/option><option value=\"Tajikistan\">Tajikistan<\/option><option value=\"Tanzania\">Tanzania<\/option><option value=\"Thailand\">Thailand<\/option><option value=\"Togo\">Togo<\/option><option value=\"Tokelau\">Tokelau<\/option><option value=\"Tonga\">Tonga<\/option><option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option value=\"Tunisia\">Tunisia<\/option><option value=\"Turkey\">Turkey<\/option><option value=\"Turkmenistan\">Turkmenistan<\/option><option value=\"Turks &amp; Caicos Islands\">Turks &amp; Caicos Islands<\/option><option value=\"Turks and Caicos Islands\">Turks and Caicos Islands<\/option><option value=\"Tuvalu\">Tuvalu<\/option><option value=\"Uganda\">Uganda<\/option><option value=\"Ukraine\">Ukraine<\/option><option value=\"United Arab Emirates\">United Arab Emirates<\/option><option value=\"United Kingdom\">United Kingdom<\/option><option value=\"Uruguay\">Uruguay<\/option><option value=\"USA Minor Outlying Islands\">USA Minor Outlying Islands<\/option><option value=\"Uzbekistan\">Uzbekistan<\/option><option value=\"Vanuatu\">Vanuatu<\/option><option value=\"Vatican City State (Holy See)\">Vatican City State (Holy See)<\/option><option value=\"Venezuela\">Venezuela<\/option><option value=\"Vietnam\">Vietnam<\/option><option value=\"Virgin Islands (British)\">Virgin Islands (British)<\/option><option value=\"Virgin Islands (U.S.)\">Virgin Islands (U.S.)<\/option><option value=\"Wallis and Futuna Islands\">Wallis and Futuna Islands<\/option><option value=\"Western Sahara\">Western Sahara<\/option><option value=\"Yemen\">Yemen<\/option><option value=\"Zambia\">Zambia<\/option><option value=\"Zimbabwe\">Zimbabwe<\/option><\/select><\/div>\n<div class=\"mc-field-group\"><label for=\"mce-MMERGE3\">State <span class=\"asterisk\">*<\/span><br \/>\n<\/label><br \/>\n<input class=\"required\" id=\"mce-MMERGE3\" type=\"text\" name=\"MMERGE3\" value=\"\" \/><\/div>\n<div class=\"mc-field-group\"><label for=\"mce-MMERGE2\">Male \/ Female <span class=\"asterisk\">*<\/span><br \/>\n<\/label><br \/>\n<select class=\"required\" id=\"mce-MMERGE2\" name=\"MMERGE2\"><option value=\"\"><\/option><option value=\"Female\">Female<\/option><option value=\"Male\">Male<\/option><option value=\"Prefer not to say\">Prefer not to say<\/option><\/select><\/div>\n<div class=\"mc-field-group\"><label for=\"mce-MMERGE6\">Age Range <span class=\"asterisk\">*<\/span><br \/>\n<\/label><br \/>\n<select class=\"required\" id=\"mce-MMERGE6\" name=\"MMERGE6\"><option value=\"\"><\/option><option value=\"18 - 25\">18 &#8211; 25<\/option><option value=\"26 - 35\">26 &#8211; 35<\/option><option value=\"36 - 45\">36 &#8211; 45<\/option><option value=\"46 - 55\">46 &#8211; 55<\/option><option value=\"56 - 65\">56 &#8211; 65<\/option><option value=\"65 +\">65 +<\/option><\/select><\/div>\n<div class=\"mc-field-group\"><label for=\"mce-MMERGE7\">What is your Current weight? <span class=\"asterisk\">*<\/span><br \/>\n<\/label><br \/>\n<input class=\"required\" id=\"mce-MMERGE7\" type=\"text\" name=\"MMERGE7\" value=\"\" \/><\/div>\n<div class=\"mc-field-group\"><label for=\"mce-MMERGE8\">What do you think is your IDEAL weight should be? <span class=\"asterisk\">*<\/span><br \/>\n<\/label><br \/>\n<input class=\"required\" id=\"mce-MMERGE8\" type=\"text\" name=\"MMERGE8\" value=\"\" \/><\/div>\n<div class=\"mc-field-group size1of2\"><label for=\"mce-MMERGE9\">At what age were you last at your ideal Weight? <\/label><br \/>\n<input id=\"mce-MMERGE9\" type=\"number\" name=\"MMERGE9\" value=\"\" \/><\/div>\n<div class=\"mc-field-group\"><label for=\"mce-MMERGE10\">What vitamins, shakes or superfoods do you take? <span class=\"asterisk\">*<\/span><br \/>\n<\/label><br \/>\n<input class=\"required\" id=\"mce-MMERGE10\" type=\"text\" name=\"MMERGE10\" value=\"\" \/><\/div>\n<div class=\"mc-field-group\"><label for=\"mce-MMERGE11\">How often do you cook Healthy Meals? <\/label><br \/>\n<select id=\"mce-MMERGE11\" name=\"MMERGE11\"><option value=\"\"><\/option><option value=\"Less than Once per week\">Less than Once per week<\/option><option value=\"1 - 2 meals per week\">1 &#8211; 2 meals per week<\/option><option value=\"3 - 4 meals per week\">3 &#8211; 4 meals per week<\/option><option value=\"5 - 6 meals per week\">5 &#8211; 6 meals per week<\/option><option value=\"7 + meals per week\">7 + meals per week<\/option><\/select><\/div>\n<div class=\"mc-field-group\"><label for=\"mce-MMERGE12\">How often do you exercise? <\/label><br \/>\n<select id=\"mce-MMERGE12\" name=\"MMERGE12\"><option value=\"\"><\/option><option value=\"Less than Once per Week\">Less than Once per Week<\/option><option value=\"1 day per week\">1 day per week<\/option><option value=\"2 days per week\">2 days per week<\/option><option value=\"3 days per week\">3 days per week<\/option><option value=\"4 days per week\">4 days per week<\/option><option value=\"5 days per week\">5 days per week<\/option><option value=\"6 days per week\">6 days per week<\/option><option value=\"7 days per week\">7 days per week<\/option><option value=\"7 + days per week\">7 + days per week<\/option><\/select><\/div>\n<div class=\"mc-field-group\"><label for=\"mce-MMERGE13\">What would you like to improve MOST w\/this plan? <span class=\"asterisk\">*<\/span><br \/>\n<\/label><br \/>\n<select class=\"required\" id=\"mce-MMERGE13\" name=\"MMERGE13\"><option value=\"\"><\/option><option value=\"Release Some Fat\">Release Some Fat<\/option><option value=\"Gain More Energy\">Gain More Energy<\/option><option value=\"Learn a Specific way to get your Nutrients\">Learn a Specific way to get your Nutrients<\/option><option value=\"Learn Easy, Simple &amp; Highly Effective Exercises\">Learn Easy, Simple &amp; Highly Effective Exercises<\/option><\/select><\/div>\n<div class=\"mc-field-group\"><label for=\"mce-MMERGE14\">Rate your energy level on a scale 1 &#8211; 10 (10 best) <span class=\"asterisk\">*<\/span><br \/>\n<\/label><br \/>\n<select class=\"required\" id=\"mce-MMERGE14\" name=\"MMERGE14\"><option value=\"\"><\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><\/select><\/div>\n<div class=\"mc-field-group\"><label for=\"mce-MMERGE15\">Rate your stress level (10 = Totally STRESSED) <span class=\"asterisk\">*<\/span><br \/>\n<\/label><br \/>\n<select class=\"required\" id=\"mce-MMERGE15\" name=\"MMERGE15\"><option value=\"\"><\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><\/select><\/div>\n<div class=\"mc-field-group\"><label for=\"mce-MMERGE16\">Tell us why you need to take action today. <\/label><br \/>\n<input id=\"mce-MMERGE16\" type=\"text\" name=\"MMERGE16\" value=\"\" \/><\/div>\n<div class=\"mc-field-group\"><label for=\"mce-MMERGE17\">How will your Life be Better by reaching your goal <\/label><br \/>\n<input id=\"mce-MMERGE17\" type=\"text\" name=\"MMERGE17\" value=\"\" \/><\/div>\n<div class=\"mc-field-group\"><label for=\"mce-MMERGE18\">What will happen if you don&#8217;t make a change? <\/label><br \/>\n<input id=\"mce-MMERGE18\" type=\"text\" name=\"MMERGE18\" value=\"\" \/><\/div>\n<div class=\"mc-field-group\"><label for=\"mce-MMERGE19\">Choose Your Fire Body Coach <span class=\"asterisk\">*<\/span><br \/>\n<\/label><br \/>\n<select class=\"required\" id=\"mce-MMERGE19\" name=\"MMERGE19\"><option value=\"\"><\/option><option value=\"I Don't Know Who I Would Choose\">I Don&#8217;t Know Who I Would Choose<\/option><option value=\"Dr. John Surie - Owner\">Dr. John Surie &#8211; Owner<\/option><option value=\"Natalie Surie - Owner\">Natalie Surie &#8211; Owner<\/option><option value=\"Naomi Camilleri\">Naomi Camilleri<\/option><option value=\"Kanan Kapila\">Kanan Kapila<\/option><option value=\"Stefanie Surie\">Stefanie Surie<\/option><\/select><\/div>\n<div class=\"clear\" id=\"mce-responses\"><\/div>\n<p><!-- real people should not fill this in and expect good things - do not remove this or risk form bot signups--><\/p>\n<div style=\"position: absolute; left: -5000px;\"><input tabindex=\"-1\" type=\"text\" 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