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Form analysis
1 forms found in the DOM

POST /registration.tmpl

<form id="registrationForm" action="/registration.tmpl" method="POST">
  <section class="datetimes price">
    <div class="pad-container dataTime-outer-container">
      <div class="calendar-container">
        <div class="date-container-month">Sep</div>
        <div class="date-container-date">27</div>
        <div class="date-container-day">Wed</div>
      </div>
      <div class="pad-container dataTimes-inner-container">
        <input type="hidden" id="registrant-tz" name="registrant.timeZone" value="Europe/Berlin">
        <div class="trainingTimesBox">
          <div class="singleinsta">
            <div id="tr-time-list">
              <ul class="all-times" box_h="79" style="height: 100px;">
                <li class="next">Wed, Sep 27, 2023 <span>7:15 PM - 8:15 PM CEST</span></li>
              </ul>
            </div>
            <a id="show-tz-btn" class="timezone" data-toggle="modal" data-target="#myModal-timezone" href="#timezone-modal">
                                <span>Change time zone</span>
                                </a>
          </div>
        </div>
      </div>
    </div>
  </section>
  <section class="custo-reg-form no-flow">
    <div class="pad-container">
      <small class="req">*required field</small>
      <div id="studentInformation">
        <input type="hidden" id="training" name="training" value="2211820904863302913">
        <div class="formField even required">
          <label id="registrant.givenNameLabel">First Name</label>
          <input type="text" id="registrant.givenName" class="maxCharLimit" name="registrant.givenName" value="" maxlength="128" tabindex="1">
        </div>
        <div class="formField odd required">
          <label id="registrant.surnameLabel">Last Name</label>
          <input type="text" id="registrant.surname" class="maxCharLimit" name="registrant.surname" value="" maxlength="128" tabindex="2">
        </div>
        <div class="formField even required">
          <label id="registrant.emailLabel">Email Address</label>
          <input type="email" id="registrant.email" class="maxCharLimit" name="registrant.email" value="" maxlength="128" tabindex="3">
        </div>
        <div class="formField odd required">
          <label id="registrant.phoneLabel">Phone</label>
          <input type="text" id="registrant.phone" class="maxCharLimit" name="registrant.phone" value="" maxlength="128" tabindex="4">
        </div>
      </div>
      <p class="registrationWarning" style="padding: 15px 0; clear:both;">Training organizers are prohibited from soliciting confidential personal information (credit card information, social security numbers, etc.) in the registration form. This
        questionnaire is not intended to handle sensitive data.</p>
      <div id="customQuestions">
        <div class="formField required">
          <input type="hidden" name="customRegistrationSubmission.answers[0].questionKey" value="38917899">
          <div class="control-block customques">
            <label id="customRegistrationSubmission.answers_0.textLabel" class="">Insurance License #</label>
            <textarea id="customRegistrationSubmission.answers_0.text" name="customRegistrationSubmission.answers[0].text" class="" tabindex="5" rows="0" cols="0"></textarea>
            <p class="help-block"></p>
          </div>
        </div>
      </div>
      <div class="infoMessage">
        <p>By clicking this button you submit your information to the training organizer, who will use it to communicate with you regarding this event and their other services.</p>
      </div>
      <div class="sectionFooter">
        <p>
          <label for="registration.submit.button" class="symphony-button">
            <span>Register</span>
            <input id="registration.submit.button" type="submit" value="Register" tabindex="6">
          </label>
          <input type="hidden" id="error_givenname" name="error_givenname" value="Enter your first name.">
          <input type="hidden" id="error_surname" name="error_surname" value="Enter your last name.">
          <input type="hidden" id="error_street_address" name="error_street_address" value="Enter your street address.">
          <input type="hidden" id="error_email_address" name="error_email_address" value="Enter a valid email address.">
          <input type="hidden" id="error_city" name="error_city" value="Enter your city.">
          <input type="hidden" id="error_state" name="error_state" value="Enter your state/province.">
          <input type="hidden" id="error_zip" name="error_zip" value="Enter your zip/postal code.">
          <input type="hidden" id="error_country" name="error_country" value="Enter your country.">
          <input type="hidden" id="error_phone" name="error_phone" value="Enter your phone.">
          <input type="hidden" id="error_organization" name="error_organization" value="Enter your organization.">
          <input type="hidden" id="error_job_title" name="error_job_title" value="Enter your job title.">
          <input type="hidden" id="error_comments" name="error_comments" value="Enter your answer.">
          <input type="hidden" id="error_custom_question" name="error_custom_question" value="Enter your answer.">
          <input type="hidden" id="error_choose_one" name="error_chooseOne" value="Choose an option.">
        </p>
      </div>
    </div>
  </section>
</form>

Text Content

PLEASE REGISTER FOR 'SENIOR ISSUES - 09/27'



Senior Issues - 09/27 - This course is good for 1 hour CE for Life & Health

Contact Organizer
Sep
27
Wed
 * Wed, Sep 27, 2023 7:15 PM - 8:15 PM CEST

Change time zone
*required field
First Name
Last Name
Email Address
Phone

Training organizers are prohibited from soliciting confidential personal
information (credit card information, social security numbers, etc.) in the
registration form. This questionnaire is not intended to handle sensitive data.

Insurance License #



By clicking this button you submit your information to the training organizer,
who will use it to communicate with you regarding this event and their other
services.

Register

Close Your information will be submitted to the training organizer, who will use
it to communicate with you regarding this event and their other services.

×

MORE INFORMATION

 * Email Organizer

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REFUND POLICY

For information regarding cancellations and refunds, please contact the training
organizer at info.mikeruss@gmail.com.
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ARE YOU SURE?

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