events.charliehealth.com Open in urlscan Pro
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1 forms found in the DOM

POST https://events.charliehealth.com/reg/lKBS27tIZG0e08m3?utm_source=Iterable&utm_medium=Email&utm_campaign=MultiEvent

<form class="demio-registration-form demio-embed-form-responsive demio-embed-form" novalidate="" target="_top" method="post"
  action="https://events.charliehealth.com/reg/lKBS27tIZG0e08m3?utm_source=Iterable&amp;utm_medium=Email&amp;utm_campaign=MultiEvent" enctype="application/x-www-form-urlencoded">
  <div class="demio-form-field">
    <div id="demio-calendar"></div>
  </div>
  <div class="demio-form-field-container">
    <div class="Demio-Input-field"><label for="name"><span class="Demio-Input-label">First Name</span>
        <div class="Demio-Input-container"><input id="name" type="text" name="name" placeholder="First Name" required="" maxlength="120" autocomplete="off" value=""></div>
      </label></div>
  </div>
  <div class="demio-form-field-container">
    <div class="Demio-Input-field"><label for="last_name"><span class="Demio-Input-label">Last Name</span>
        <div class="Demio-Input-container"><input id="last_name" type="text" name="last_name" placeholder="Last Name" required="" maxlength="120" autocomplete="off" value=""></div>
      </label></div>
  </div>
  <div class="demio-form-field-container">
    <div class="Demio-Input-field"><label for="email"><span class="Demio-Input-label">Email</span>
        <div class="Demio-Input-container"><input id="email" type="email" name="email" placeholder="Email" required="" maxlength="254" autocomplete="off" value=""></div>
      </label></div>
  </div>
  <div class="demio-form-field-container">
    <div class="Demio-Input-field"><label for="ef6744a0-d62b-4d55-9f03-139c040b91e6"><span class="Demio-Input-label">Personal Email Address (optional)</span><span class="Demio-Input-label-optional">Optional</span>
        <div class="Demio-Input-container"><input id="ef6744a0-d62b-4d55-9f03-139c040b91e6" type="text" name="ef6744a0-d62b-4d55-9f03-139c040b91e6" placeholder="Personal Email Address (optional)" maxlength="120" autocomplete="off" value=""></div>
      </label></div>
  </div>
  <div class="demio-form-field-container">
    <div class="Demio-Input-field"><label for="4db019f0-4852-4139-aca2-4d840d9caf6f"><span class="Demio-Input-label">Mobile Phone Number</span>
        <div class="Demio-Input-container"><input id="4db019f0-4852-4139-aca2-4d840d9caf6f" type="text" name="4db019f0-4852-4139-aca2-4d840d9caf6f" placeholder="Mobile Phone Number" required="" maxlength="120" autocomplete="off" value=""></div>
      </label></div>
  </div>
  <div class="demio-form-field-container">
    <div class="Demio-Input-field"><label for="b10bc163-f453-4085-a933-887d310c487b"><span class="Demio-Input-label">Credentials (List N/A if not applicable)</span>
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            value=""></div>
      </label></div>
  </div>
  <div class="demio-form-field-container">
    <div class="Demio-Input-field"><label for="a1b04588-ea0b-429b-b25f-f560fda55889"><span class="Demio-Input-label">Name of Organization</span>
        <div class="Demio-Input-container"><input id="a1b04588-ea0b-429b-b25f-f560fda55889" type="text" name="a1b04588-ea0b-429b-b25f-f560fda55889" placeholder="Name of Organization" required="" maxlength="120" autocomplete="off" value=""></div>
      </label></div>
  </div>
  <div class="demio-form-field-container">
    <div class="Demio-Input-field"><label for="9185d85a-416d-4e2a-a937-f25509c96700"><span class="Demio-Input-label">State of Residence</span>
        <div class="Demio-Input-container"><input id="9185d85a-416d-4e2a-a937-f25509c96700" type="text" name="9185d85a-416d-4e2a-a937-f25509c96700" placeholder="State of Residence" required="" maxlength="120" autocomplete="off" value=""></div>
      </label></div>
  </div><input type="hidden" name="demio-country" value="DE"><input type="hidden" name="referral_url" value=""><button type="submit"
    class="ant-btn registration-submit-button Button animated fadeIn --full-size ant-btn-primary"><span>REGISTER</span></button>
  <div class="demio-embed-noti">By registering, you agree to the <a target="_blank" rel="noreferrer" href="https://demio.com/registration-terms-and-conditions">terms</a> and
    <a target="_blank" rel="noreferrer" href="https://www.banzai.io/legal/privacy-policy">privacy policy</a>.</div>
</form>

Text Content

Breaking the Stigma: The Intersection of Chronic Illness and Mental Health
When registering, it is required to do so using your professional, clinical
email.
Thursday, August 17th 2023 @ 7:00PM GMT
08 days
06 hours
41 minutes
55 seconds
First Name

Last Name

Email

Personal Email Address (optional)Optional

Mobile Phone Number

Credentials (List N/A if not applicable)

Name of Organization

State of Residence

REGISTER
By registering, you agree to the terms and privacy policy.

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