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nachw.org Open in urlscan Pro
2620:12a:8001::4  Public Scan

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URL: https://nachw.org/covid-test-kit-order-form/
Submission: On January 18 via manual from US — Scanned from DE

Form analysis 3 forms found in the DOM

POST /covid-test-kit-order-form/

<form method="post" enctype="multipart/form-data" id="gform_6" class="covidrapidtest zipcode recaptcha-v3-initialized" action="/covid-test-kit-order-form/">
  <div class="gf_invisible ginput_recaptchav3" data-sitekey="6LeHrhEeAAAAAJ0qvc897QnY_Csa6mrGIApW5paf" data-tabindex="0"><input id="input_20e83e33877d793f7993387d5bcc502e" class="gfield_recaptcha_response" type="hidden"
      name="input_20e83e33877d793f7993387d5bcc502e" value=""></div>
  <div class="gform_body gform-body">
    <div id="gform_fields_6" class="gform_fields top_label form_sublabel_below description_below">
      <fieldset id="field_6_1" class="gfield gfield_contains_required field_sublabel_hidden_label field_description_below gfield_visibility_visible">
        <legend class="gfield_label gfield_label_before_complex">Zip Code<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
        <div class="ginput_complex ginput_container has_zip ginput_container_address" id="input_6_1">
          <input type="hidden" class="gform_hidden" name="input_1.4" id="input_6_1_4" value=""><span class="ginput_right address_zip ginput_address_zip" id="input_6_1_5_container">
            <input type="text" name="input_1.5" id="input_6_1_5" value="" aria-required="true">
            <label for="input_6_1_5" id="input_6_1_5_label" class="hidden_sub_label screen-reader-text">ZIP Code</label>
          </span><input type="hidden" class="gform_hidden" name="input_1.6" id="input_6_1_6" value="United States">
          <div class="gf_clear gf_clear_complex"></div>
        </div>
      </fieldset>
      <div id="field_6_2" class="gfield gform_validation_container field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_6_2">Name</label>
        <div class="ginput_container"><input name="input_2" id="input_6_2" type="text" value=""></div>
        <div class="gfield_description" id="gfield_description_6_2">This field is for validation purposes and should be left unchanged.</div>
      </div>
    </div>
  </div>
  <div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_6" class="gform_button button" value="Submit" onclick="if(window[&quot;gf_submitting_6&quot;]){return false;}  window[&quot;gf_submitting_6&quot;]=true;  "
      onkeypress="if( event.keyCode == 13 ){ if(window[&quot;gf_submitting_6&quot;]){return false;} window[&quot;gf_submitting_6&quot;]=true;  jQuery(&quot;#gform_6&quot;).trigger(&quot;submit&quot;,[true]); }">
    <input type="hidden" class="gform_hidden" name="is_submit_6" value="1">
    <input type="hidden" class="gform_hidden" name="gform_submit" value="6">
    <input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
    <input type="hidden" class="gform_hidden" name="state_6" value="WyJbXSIsIjRkN2QxZjJiMTM0ZjYzMGM3NjYwZTEyODYyZGVkNTFlIl0=">
    <input type="hidden" class="gform_hidden" name="gform_target_page_number_6" id="gform_target_page_number_6" value="0">
    <input type="hidden" class="gform_hidden" name="gform_source_page_number_6" id="gform_source_page_number_6" value="1">
    <input type="hidden" name="gform_field_values" value="">
  </div>
</form>

Name: mc-embedded-subscribe-form — POST https://nachw.us19.list-manage.com/subscribe/post?u=f2fbfbbea77a24e8da555eaee&id=b67b0e272a

<form action="https://nachw.us19.list-manage.com/subscribe/post?u=f2fbfbbea77a24e8da555eaee&amp;id=b67b0e272a" method="post" id="mc-embedded-subscribe-form" name="mc-embedded-subscribe-form" class="validate" target="_blank" novalidate="">
  <div id="mc_embed_signup_scroll">
    <div class="MailChimp-inputs">
      <input type="email" value="" name="EMAIL" class="email" id="mce-EMAIL" placeholder="your@email.com" required="">
      <input type="submit" value="Subscribe" name="subscribe" id="mc-embedded-subscribe" class="button submit">
      <div class="clear"></div>
    </div>
    <div style="position: absolute; left: -5000px;" aria-hidden="true"><input type="text" name="b_f2fbfbbea77a24e8da555eaee_b67b0e272a" tabindex="-1" value=""></div>
  </div>
</form>

Name: loginform — POST https://nachw.org/wp-login.php

<form name="loginform" id="loginform" action="https://nachw.org/wp-login.php" method="post">
  <p class="login-username">
    <label for="user_login">Username or Email Address</label>
    <input type="text" name="log" id="user_login" class="input" value="" size="20">
  </p>
  <p class="login-password">
    <label for="user_pass">Password</label>
    <input type="password" name="pwd" id="user_pass" class="input" value="" size="20">
  </p>
  <p class="login-remember"><label><input name="rememberme" type="checkbox" id="rememberme" value="forever"> Remember Me</label></p>
  <p class="login-submit">
    <input type="submit" name="wp-submit" id="wp-submit" class="button button-primary" value="Log In">
    <input type="hidden" name="redirect_to" value="https://nachw.org/covid-test-kit-order-form/">
  </p>
</form>

Text Content

NACHW NACHW
 * Login

 * Login
 * Become A Member

 * About
   * NACHW Committees
 * COVID-19
   * National COVID-19 Resiliency Network (NCRN)
 * Policies
   * Policies
   * CHW Document Resource Center
 * Membership
   * CHW Networks and Training Programs
 * News
 * Events
   * NACHW Learning Collaboratives
 * Connect
   * NACHW Partnerships and Sponsorships
 * Become A Member

NACHW

 * ›About
   * NACHW Committees
 * ›COVID-19
   * National COVID-19 Resiliency Network (NCRN)
 * ›Policies
   * Policies
   * CHW Document Resource Center
 * ›Membership
   * CHW Networks and Training Programs
 * News
 * ›Events
   * NACHW Learning Collaboratives
 * ›Connect
   * NACHW Partnerships and Sponsorships
 * Become A Member

 * Login
   




COVID TEST KIT ORDER FORM

Please enter your zip code. Orders will be prioritized for equitable
distribution based on communities that are hardest hit by the COVID-19 pandemic.

Zip Code(Required)
ZIP Code

Name

This field is for validation purposes and should be left unchanged.



SIGN UP TO STAY UP TO DATE!


 * About
 * COVID-19
 * Policies
 * Membership
 * News
 * Events
 * Connect
 * Become A Member

 * Login
 * Become A Member

© 2022 NACHW. All rights reserved.
 * 


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