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form.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="utf-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta name="viewport" content="width=device-width, initial-scale=1">
<link rel="icon" href="favicon.ico">
<title>Register your interest - Let's Get Coding</title>
<link rel="stylesheet" href="https://maxcdn.bootstrapcdn.com/bootstrap/3.2.0/css/bootstrap.min.css">
<link rel="stylesheet" href="https://maxcdn.bootstrapcdn.com/font-awesome/4.2.0/css/font-awesome.min.css">
<link rel="stylesheet" href="css/letsgetcoding.css">
<!--[if lt IE 9]>
<script src="https://oss.maxcdn.com/html5shiv/3.7.2/html5shiv.min.js"></script>
<script src="https://oss.maxcdn.com/respond/1.4.2/respond.min.js"></script>
<![endif]-->
</head>
<body>
<form name="insightly_web_to_contact" class="center-block" id="form" role="form" action="https://letsgetcoding.insight.ly/WebToContact/Create" method="post">
<input type="hidden" name="formId" value="KqeV7VhwKfbaddnpRiXTvQ==">
<input type="hidden" name="addresses[0].AddressType" value="Other">
<input type="hidden" name="addresses[0].Street" value="">
<input type="hidden" name="addresses[0].PostalCode" value="">
<input type="hidden" name="addresses[0].Country" value="Australia">
<div class="form-group">
<label class="radio-inline">
<input type="radio" name="Role" value="Parent" checked> Parent
</label>
<label class="radio-inline">
<input type="radio" name="Role" value="Principal"> Principal
</label>
<label class="radio-inline">
<input type="radio" name="Role" value="Teacher"> Teacher
</label>
<label class="radio-inline">
<input type="radio" name="Role" value="Other"> Other
</label>
</div>
<div class="form-group">
<div class="row">
<div class="col-xs-6">
<label for="FirstName" class="sr-only">Your first name</label>
<input type="text" name="FirstName" class="form-control" id="FirstName" placeholder="Your first name" required>
</div>
<div class="col-xs-6">
<label for="LastName" class="sr-only">Your last name</label>
<input type="text" name="LastName" class="form-control" id="LastName" placeholder="Your last name" required>
</div>
</div>
</div>
<div class="form-group">
<input type="hidden" name="emails[0].Label" value="Other">
<label for="Email" class="sr-only">Your email address</label>
<input type="email" name="emails[0].Value" class="form-control" id="Email" placeholder="Your email address" required>
</div>
<div class="form-group">
<label for="Children" class="sr-only">Your child's name</label>
<textarea name="background" class="form-control" id="Children" rows="4" placeholder="If you're a parent and are registering interest for your child/children, let us know their names so we can add them to the waiting list."></textarea>
</div>
<div class="form-group">
<label for="Organization" class="sr-only">School name</label>
<input type="text" name="Organization" class="form-control" id="Organization" placeholder="School name" required>
</div>
<div class="form-group">
<label for="Suburb" class="sr-only">School suburb</label>
<input type="text" name="addresses[0].City" class="form-control" id="Suburb" placeholder="School suburb" required>
</div>
<div class="form-group">
<label for="State" class="sr-only">School state</label>
<select name="addresses[0].State" class="form-control" id="State">
<option value="">School state</option>
<option value="ACT">ACT</option>
<option value="NSW">NSW</option>
<option value="NT">NT</option>
<option value="QLD">QLD</option>
<option value="SA">SA</option>
<option value="TAS">TAS</option>
<option value="VIC">VIC</option>
<option value="WA">WA</option>
</select>
</div>
<input type="submit" value="Submit" class="btn btn-success btn-lg btn-block">
</form>
<script src="https://ajax.googleapis.com/ajax/libs/jquery/1.11.1/jquery.min.js"></script>
<script src="https://maxcdn.bootstrapcdn.com/bootstrap/3.2.0/js/bootstrap.min.js"></script>
<script>
(function(i,s,o,g,r,a,m){i['GoogleAnalyticsObject']=r;i[r]=i[r]||function(){
(i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o),
m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m)
})(window,document,'script','//www.google-analytics.com/analytics.js','ga');
ga('create', 'UA-55850512-1', 'auto');
ga('send', 'pageview');
</script>
</body>
</html>