document.write("\u003Cdiv class='top-wide noprint'\u003E\n\u003Cdiv class='trackable promo-9B' id='promo-9B'\u003E\n\u003Cform action=\"/register/to_get_a_to_do_list\" id=\"regform\" method=\"post\" name=\"regform\"\u003E\n\u003Cfieldset\u003E\n\u003Cdiv class='form_add'\u003E\u003Cinput type='text' name='reference' size='30' /\u003E\u003C/div\u003E\n\u003Cinput id=\"first_form\" name=\"first_form\" type=\"hidden\" value=\"true\" /\u003E\n\u003Cinput name='source' type='hidden' value='9B' /\u003E\n\u003Cdiv class='right-fields'\u003E\n\u003Cdl\u003E\n\u003Cdt\u003E\u003Clabel for=\"location\"\u003ELocation\u003C/label\u003E\u003C/dt\u003E\n\u003Cdd\u003E\u003Cinput id=\"location\" name=\"location\" onclick=\"if(!this.selected){this.value='';};this.selected=1;\" type=\"text\" value=\"enter zip or city \u0026amp; state\" /\u003E\u003C/dd\u003E\n\u003C/dl\u003E\n\u003Cdl\u003E\n\u003Cdt\u003E\u003Clabel for=\"email\"\u003EE-mail\u003C/label\u003E\u003C/dt\u003E\n\u003Cdd\u003E\n\u003Cinput id=\"user_email\" name=\"user[email]\" onclick=\"if(!this.selected){this.value='';};this.selected=1;\" size=\"20\" type=\"text\" value=\"enter email address\" /\u003E\n\u003C/dd\u003E\n\u003C/dl\u003E\n\u003C/div\u003E\n\u003Cdiv class='left-fields'\u003E\n\u003Cdl\u003E\n\u003Cdt\u003E\u003Clabel for=\"top_concern\"\u003ETop concern\u003C/label\u003E\u003C/dt\u003E\n\u003Cdd\u003E\n\u003Cselect name='concerning'\u003E\n\u003Coption value=\"alzheimers-dementia\" selected=\"selected\"\u003EAlzheimer's/dementia\u003C/option\u003E\n\u003Coption value=\"cancer\"\u003ECancer\u003C/option\u003E\n\u003Coption value=\"declining-health\"\u003EDeclining Health\u003C/option\u003E\n\u003Coption value=\"end-of-life\"\u003EEnd of life\u003C/option\u003E\n\u003Coption value=\"housing-arrangements\"\u003EHousing/living independently\u003C/option\u003E\n\u003Coption value=\"managing-your-parents-finances\"\u003EManaging finances\u003C/option\u003E\n\u003Coption value=\"planning-a-funeral\"\u003EPlanning a funeral\u003C/option\u003E\n\u003Coption value=\"stroke\"\u003EStroke\u003C/option\u003E\n\u003C/select\u003E\n\u003C/dd\u003E\n\u003C/dl\u003E\n\u003Cdl\u003E\n\u003Cdt\u003E\u003Clabel for=\"caring_for\"\u003ECaring for\u003C/label\u003E\u003C/dt\u003E\n\u003Cdd\u003E\n\u003Cselect name='caring_for'\u003E\n\u003Coption value=\"3305\"\u003EMom\u003C/option\u003E\n\u003Coption value=\"3306\"\u003EDad\u003C/option\u003E\n\u003Coption value=\"3308\"\u003ESpouse\u003C/option\u003E\n\u003Coption value=\"3351\"\u003ESibling\u003C/option\u003E\n\u003Coption value=\"3307\"\u003EGrandparent\u003C/option\u003E\n\u003Coption value=\"3309\"\u003EMyself\u003C/option\u003E\n\u003Coption value=\"2467\"\u003EOther\u003C/option\u003E\n\u003C/select\u003E\n\u003C/dd\u003E\n\u003C/dl\u003E\n\u003C/div\u003E\n\u003Cdiv id='submit'\u003E\n\u003Cinput id=\"submit_promo\" onclick=\"submitPromoForm(this); return false;\" onmouseout=\"promoButtonRollOut(this)\" onmouseover=\"promoButtonRollIn(this)\" src=\"http://assets0.caring.com/images/redesign/promos/top-wide/button_default.png?82fd461\" type=\"image\" /\u003E\n\u003C/div\u003E\n\u003C/fieldset\u003E\n\u003Cscript type=\"text/javascript\"\u003E\n//\u003C![CDATA[\nvar promo_location_sample = \"enter zip or city \u0026 state\";\nvar promo_invalid_email = \"You must supply a valid e-mail address.\";\nvar promo_no_location = \"You must enter a city and state or zip code.\";\nvar promo_invalid_location = \"You must tell us a valid location.\";\nfunction promoButtonRollIn(element){\n  element.src = \"/images/redesign/promos/top-wide/button_over.png\";\n}\n\nfunction promoButtonRollOut(element){\n  element.src = \"/images/redesign/promos/top-wide/button_default.png\";\n}\n\nfunction submitPromoForm(element){\n  if(isPromoFormValid()){$(element).hide();$('regform').dosubmit();}\n}\n\nfunction isPromoFormValid() {\n  if(!validEmail($F('user_email'))) {\n    alert(promo_invalid_email);\n    return false;\n  }\n  if($F('location') === promo_location_sample) {\n    alert(promo_no_location);\n    return false;\n  }\n  if(!validateMinimumLength(5)($F('location'))) {\n    alert(promo_invalid_location);\n    return false;\n  }\n  return true;\n}\n\n//]]\u003E\n\u003C/script\u003E\u003C/form\u003E\n\n\u003C/div\u003E\n\u003C/div\u003E\n");