form test - Eydie Moses-Kolko

[et_pb_section bb_built=”1″][et_pb_row][et_pb_column type=”4_4″][et_pb_contact_form _builder_version=”3.21.4″ z_index_tablet=”500″ title=”New user registration form” success_message=”Thank you for filling out the new user registration form. We will be in touch with you soon” submit_button_text=”Submit” email=”lutherandj@upmc.edu”][et_pb_contact_field field_title=”First Name” field_type=”input” field_id=”fName” required_mark=”on” fullwidth_field=”off” _builder_version=”3.21.4″ checkbox_checked=”off” checkbox_options=”%91{%22value%22:%22Name%22,%22checked%22:0}%93″ radio_options=”%91{%22value%22:%22Name%22,%22checked%22:0}%93″ select_options=”%91{%22value%22:%22Name%22,%22checked%22:0}%93″ min_length=”0″ max_length=”0″ allowed_symbols=”all” conditional_logic=”off” conditional_logic_relation=”off” conditional_logic_rules=”%91{%22field%22:%22email%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ link_option_url_new_window=”off” use_background_color_gradient=”off” background_color_gradient_start=”#2b87da” background_color_gradient_end=”#29c4a9″ background_color_gradient_type=”linear” background_color_gradient_direction=”180deg” background_color_gradient_direction_radial=”center” background_color_gradient_start_position=”0%” background_color_gradient_end_position=”100%” background_color_gradient_overlays_image=”off” parallax=”off” parallax_method=”on” background_size=”cover” background_position=”center” background_repeat=”no-repeat” background_blend=”normal” allow_player_pause=”off” background_video_pause_outside_viewport=”on” form_field_text_shadow_style=”none” box_shadow_style=”none” hover_transition_duration=”300ms” hover_transition_delay=”0ms” hover_transition_speed_curve=”ease” /][et_pb_contact_field _builder_version=”3.21.4″ field_id=”lname” field_title=”Last Name” field_type=”input” checkbox_checked=”off” checkbox_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=”0″ max_length=”0″ allowed_symbols=”all” required_mark=”on” conditional_logic=”off” conditional_logic_relation=”off” conditional_logic_rules=”%91{%22field%22:%22fname%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ link_option_url_new_window=”off” use_background_color_gradient=”off” background_color_gradient_start=”#2b87da” background_color_gradient_end=”#29c4a9″ background_color_gradient_type=”linear” background_color_gradient_direction=”180deg” background_color_gradient_direction_radial=”center” background_color_gradient_start_position=”0%” background_color_gradient_end_position=”100%” background_color_gradient_overlays_image=”off” parallax=”off” parallax_method=”on” background_size=”cover” background_position=”center” background_repeat=”no-repeat” background_blend=”normal” allow_player_pause=”off” background_video_pause_outside_viewport=”on” fullwidth_field=”off” form_field_text_shadow_style=”none” box_shadow_style=”none” hover_transition_duration=”300ms” hover_transition_delay=”0ms” hover_transition_speed_curve=”ease” /][et_pb_contact_field field_title=”Email Address” field_type=”email” field_id=”Email” required_mark=”on” fullwidth_field=”off” _builder_version=”3.21.4″ /][et_pb_contact_field _builder_version=”3.21.4″ field_id=”Degree” field_title=”Degree” field_type=”input” checkbox_checked=”off” checkbox_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=”0″ max_length=”0″ allowed_symbols=”all” required_mark=”on” conditional_logic=”off” conditional_logic_relation=”off” conditional_logic_rules=”%91{%22field%22:%22fname%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ link_option_url_new_window=”off” use_background_color_gradient=”off” background_color_gradient_start=”#2b87da” background_color_gradient_end=”#29c4a9″ background_color_gradient_type=”linear” background_color_gradient_direction=”180deg” background_color_gradient_direction_radial=”center” background_color_gradient_start_position=”0%” background_color_gradient_end_position=”100%” background_color_gradient_overlays_image=”off” parallax=”off” parallax_method=”on” background_size=”cover” background_position=”center” background_repeat=”no-repeat” background_blend=”normal” allow_player_pause=”off” background_video_pause_outside_viewport=”on” fullwidth_field=”off” form_field_text_shadow_style=”none” box_shadow_style=”none” hover_transition_duration=”300ms” hover_transition_delay=”0ms” hover_transition_speed_curve=”ease” /][et_pb_contact_field _builder_version=”3.21.4″ field_id=”Institution” field_title=”Institution” field_type=”input” checkbox_checked=”off” checkbox_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=”0″ max_length=”0″ allowed_symbols=”all” required_mark=”on” conditional_logic=”off” conditional_logic_relation=”off” conditional_logic_rules=”%91{%22field%22:%22fname%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ link_option_url_new_window=”off” use_background_color_gradient=”off” background_color_gradient_start=”#2b87da” background_color_gradient_end=”#29c4a9″ background_color_gradient_type=”linear” background_color_gradient_direction=”180deg” background_color_gradient_direction_radial=”center” background_color_gradient_start_position=”0%” background_color_gradient_end_position=”100%” background_color_gradient_overlays_image=”off” parallax=”off” parallax_method=”on” background_size=”cover” background_position=”center” background_repeat=”no-repeat” background_blend=”normal” allow_player_pause=”off” background_video_pause_outside_viewport=”on” fullwidth_field=”off” form_field_text_shadow_style=”none” box_shadow_style=”none” hover_transition_duration=”300ms” hover_transition_delay=”0ms” hover_transition_speed_curve=”ease” /][et_pb_contact_field _builder_version=”3.21.4″ field_id=”Address1_” field_title=”Address Line 1″ field_type=”input” checkbox_checked=”off” checkbox_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=”0″ max_length=”0″ allowed_symbols=”all” required_mark=”on” conditional_logic=”off” conditional_logic_relation=”off” conditional_logic_rules=”%91{%22field%22:%22fname%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ link_option_url_new_window=”off” use_background_color_gradient=”off” background_color_gradient_start=”#2b87da” background_color_gradient_end=”#29c4a9″ background_color_gradient_type=”linear” background_color_gradient_direction=”180deg” background_color_gradient_direction_radial=”center” background_color_gradient_start_position=”0%” background_color_gradient_end_position=”100%” background_color_gradient_overlays_image=”off” parallax=”off” parallax_method=”on” background_size=”cover” background_position=”center” background_repeat=”no-repeat” background_blend=”normal” allow_player_pause=”off” background_video_pause_outside_viewport=”on” fullwidth_field=”off” form_field_text_shadow_style=”none” box_shadow_style=”none” hover_transition_duration=”300ms” hover_transition_delay=”0ms” hover_transition_speed_curve=”ease” /][et_pb_contact_field _builder_version=”3.21.4″ field_id=”Address2″ field_title=”Address Line 2″ field_type=”input” checkbox_checked=”off” checkbox_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=”0″ max_length=”0″ allowed_symbols=”all” required_mark=”on” conditional_logic=”off” conditional_logic_relation=”off” conditional_logic_rules=”%91{%22field%22:%22fname%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ link_option_url_new_window=”off” use_background_color_gradient=”off” background_color_gradient_start=”#2b87da” background_color_gradient_end=”#29c4a9″ background_color_gradient_type=”linear” background_color_gradient_direction=”180deg” background_color_gradient_direction_radial=”center” background_color_gradient_start_position=”0%” background_color_gradient_end_position=”100%” background_color_gradient_overlays_image=”off” parallax=”off” parallax_method=”on” background_size=”cover” background_position=”center” background_repeat=”no-repeat” background_blend=”normal” allow_player_pause=”off” background_video_pause_outside_viewport=”on” fullwidth_field=”off” form_field_text_shadow_style=”none” box_shadow_style=”none” hover_transition_duration=”300ms” hover_transition_delay=”0ms” hover_transition_speed_curve=”ease” /][et_pb_contact_field _builder_version=”3.21.4″ field_id=”City” field_title=”City” field_type=”input” checkbox_checked=”off” checkbox_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=”0″ max_length=”0″ allowed_symbols=”all” required_mark=”on” conditional_logic=”off” conditional_logic_relation=”off” conditional_logic_rules=”%91{%22field%22:%22fname%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ link_option_url_new_window=”off” use_background_color_gradient=”off” background_color_gradient_start=”#2b87da” background_color_gradient_end=”#29c4a9″ background_color_gradient_type=”linear” background_color_gradient_direction=”180deg” background_color_gradient_direction_radial=”center” background_color_gradient_start_position=”0%” background_color_gradient_end_position=”100%” background_color_gradient_overlays_image=”off” parallax=”off” parallax_method=”on” background_size=”cover” background_position=”center” background_repeat=”no-repeat” background_blend=”normal” allow_player_pause=”off” background_video_pause_outside_viewport=”on” fullwidth_field=”off” form_field_text_shadow_style=”none” box_shadow_style=”none” hover_transition_duration=”300ms” hover_transition_delay=”0ms” hover_transition_speed_curve=”ease” /][et_pb_contact_field _builder_version=”3.21.4″ field_id=”State” field_title=”State” field_type=”select” checkbox_checked=”off” checkbox_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=”%91{%22value%22:%22Alabama%22,%22checked%22:0},{%22value%22:%22Alaska%22,%22checked%22:0},{%22value%22:%22Arizona%22,%22checked%22:0},{%22value%22:%22Arkansas%22,%22checked%22:0}%93″ min_length=”0″ max_length=”0″ allowed_symbols=”all” required_mark=”on” conditional_logic=”off” conditional_logic_relation=”off” conditional_logic_rules=”%91{%22field%22:%22fname%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ link_option_url_new_window=”off” use_background_color_gradient=”off” background_color_gradient_start=”#2b87da” background_color_gradient_end=”#29c4a9″ background_color_gradient_type=”linear” background_color_gradient_direction=”180deg” background_color_gradient_direction_radial=”center” background_color_gradient_start_position=”0%” background_color_gradient_end_position=”100%” background_color_gradient_overlays_image=”off” parallax=”off” parallax_method=”on” background_size=”cover” background_position=”center” background_repeat=”no-repeat” background_blend=”normal” allow_player_pause=”off” background_video_pause_outside_viewport=”on” fullwidth_field=”off” form_field_text_shadow_style=”none” box_shadow_style=”none” hover_transition_duration=”300ms” hover_transition_delay=”0ms” hover_transition_speed_curve=”ease” /][et_pb_contact_field _builder_version=”3.21.4″ field_id=”Zip” field_title=”Zip” field_type=”input” checkbox_checked=”off” checkbox_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=”0″ max_length=”0″ allowed_symbols=”numbers” required_mark=”on” conditional_logic=”off” conditional_logic_relation=”off” conditional_logic_rules=”%91{%22field%22:%22fname%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ link_option_url_new_window=”off” use_background_color_gradient=”off” background_color_gradient_start=”#2b87da” background_color_gradient_end=”#29c4a9″ background_color_gradient_type=”linear” background_color_gradient_direction=”180deg” background_color_gradient_direction_radial=”center” background_color_gradient_start_position=”0%” background_color_gradient_end_position=”100%” background_color_gradient_overlays_image=”off” parallax=”off” parallax_method=”on” background_size=”cover” background_position=”center” background_repeat=”no-repeat” background_blend=”normal” allow_player_pause=”off” background_video_pause_outside_viewport=”on” fullwidth_field=”off” form_field_text_shadow_style=”none” box_shadow_style=”none” hover_transition_duration=”300ms” hover_transition_delay=”0ms” hover_transition_speed_curve=”ease” /][et_pb_contact_field _builder_version=”3.21.4″ field_id=”Phone” field_title=”Phone” field_type=”input” checkbox_checked=”off” checkbox_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=”0″ max_length=”0″ allowed_symbols=”all” required_mark=”on” conditional_logic=”off” conditional_logic_relation=”off” conditional_logic_rules=”%91{%22field%22:%22fname%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ link_option_url_new_window=”off” use_background_color_gradient=”off” background_color_gradient_start=”#2b87da” background_color_gradient_end=”#29c4a9″ background_color_gradient_type=”linear” background_color_gradient_direction=”180deg” background_color_gradient_direction_radial=”center” background_color_gradient_start_position=”0%” background_color_gradient_end_position=”100%” background_color_gradient_overlays_image=”off” parallax=”off” parallax_method=”on” background_size=”cover” background_position=”center” background_repeat=”no-repeat” background_blend=”normal” allow_player_pause=”off” background_video_pause_outside_viewport=”on” fullwidth_field=”off” form_field_text_shadow_style=”none” box_shadow_style=”none” hover_transition_duration=”300ms” hover_transition_delay=”0ms” hover_transition_speed_curve=”ease” /][et_pb_contact_field field_title=”Where did you hear about us?” field_type=”text” field_id=”Where_did_you_hear_about_us” required_mark=”on” fullwidth_field=”on” _builder_version=”3.21.4″ checkbox_checked=”off” checkbox_options=”%91{%22value%22:%22Message%22,%22checked%22:0}%93″ radio_options=”%91{%22value%22:%22Message%22,%22checked%22:0}%93″ select_options=”%91{%22value%22:%22Message%22,%22checked%22:0}%93″ min_length=”0″ max_length=”0″ allowed_symbols=”all” conditional_logic=”off” conditional_logic_relation=”off” conditional_logic_rules=”%91{%22field%22:%22fname%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ link_option_url_new_window=”off” use_background_color_gradient=”off” background_color_gradient_start=”#2b87da” background_color_gradient_end=”#29c4a9″ background_color_gradient_type=”linear” background_color_gradient_direction=”180deg” background_color_gradient_direction_radial=”center” background_color_gradient_start_position=”0%” background_color_gradient_end_position=”100%” background_color_gradient_overlays_image=”off” parallax=”off” parallax_method=”on” background_size=”cover” background_position=”center” background_repeat=”no-repeat” background_blend=”normal” allow_player_pause=”off” background_video_pause_outside_viewport=”on” form_field_text_shadow_style=”none” box_shadow_style=”none” hover_transition_duration=”300ms” hover_transition_delay=”0ms” hover_transition_speed_curve=”ease” /][et_pb_contact_field _builder_version=”3.21.4″ field_id=”email_distribution_List” field_title=”Would you like to be included in the email distribution list” field_type=”radio” checkbox_checked=”off” checkbox_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0},{%22value%22:%22No%22,%22checked%22:0}%93″ select_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=”0″ max_length=”0″ allowed_symbols=”all” required_mark=”on” conditional_logic=”off” conditional_logic_relation=”off” conditional_logic_rules=”%91{%22field%22:%22fname%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ link_option_url_new_window=”off” use_background_color_gradient=”off” background_color_gradient_start=”#2b87da” background_color_gradient_end=”#29c4a9″ background_color_gradient_type=”linear” background_color_gradient_direction=”180deg” background_color_gradient_direction_radial=”center” background_color_gradient_start_position=”0%” background_color_gradient_end_position=”100%” background_color_gradient_overlays_image=”off” parallax=”off” parallax_method=”on” background_size=”cover” background_position=”center” background_repeat=”no-repeat” background_blend=”normal” allow_player_pause=”off” background_video_pause_outside_viewport=”on” fullwidth_field=”off” form_field_text_shadow_style=”none” box_shadow_style=”none” hover_transition_duration=”300ms” hover_transition_delay=”0ms” hover_transition_speed_curve=”ease” /][et_pb_contact_field _builder_version=”3.21.4″ field_id=”Field_14″ field_title=”New Field” field_type=”input” checkbox_checked=”off” checkbox_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=”0″ max_length=”0″ allowed_symbols=”all” required_mark=”on” conditional_logic=”off” conditional_logic_relation=”off” conditional_logic_rules=”%91{%22field%22:%22fname%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ link_option_url_new_window=”off” use_background_color_gradient=”off” background_color_gradient_start=”#2b87da” background_color_gradient_end=”#29c4a9″ background_color_gradient_type=”linear” background_color_gradient_direction=”180deg” background_color_gradient_direction_radial=”center” background_color_gradient_start_position=”0%” background_color_gradient_end_position=”100%” background_color_gradient_overlays_image=”off” parallax=”off” parallax_method=”on” background_size=”cover” background_position=”center” background_repeat=”no-repeat” background_blend=”normal” allow_player_pause=”off” background_video_pause_outside_viewport=”on” fullwidth_field=”off” form_field_text_shadow_style=”none” box_shadow_style=”none” hover_transition_duration=”300ms” hover_transition_delay=”0ms” hover_transition_speed_curve=”ease” /][et_pb_contact_field _builder_version=”3.21.4″ field_id=”Subject” field_title=”New User Registration form” field_type=”input” checkbox_checked=”off” checkbox_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ radio_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ select_options=”%91{%22value%22:%22%22,%22checked%22:0}%93″ min_length=”0″ max_length=”0″ allowed_symbols=”all” required_mark=”off” conditional_logic=”off” conditional_logic_relation=”off” conditional_logic_rules=”%91{%22field%22:%22fname%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ link_option_url_new_window=”off” use_background_color_gradient=”off” background_color_gradient_start=”#2b87da” background_color_gradient_end=”#29c4a9″ background_color_gradient_type=”linear” background_color_gradient_direction=”180deg” background_color_gradient_direction_radial=”center” background_color_gradient_start_position=”0%” background_color_gradient_end_position=”100%” background_color_gradient_overlays_image=”off” parallax=”off” parallax_method=”on” background_size=”cover” background_position=”center” background_repeat=”no-repeat” background_blend=”normal” allow_player_pause=”off” background_video_pause_outside_viewport=”on” fullwidth_field=”off” form_field_text_shadow_style=”none” box_shadow_style=”none” hover_transition_duration=”300ms” hover_transition_delay=”0ms” hover_transition_speed_curve=”ease” /][/et_pb_contact_form][/et_pb_column][/et_pb_row][/et_pb_section]