document.writeln('<form action="https:\/\/recreateyourlife.infusionsoft.com\/AddForms\/processFormSecure.jsp" method=\'POST\'>\r\n<input id="infusion_xid" value="d930acfbb5eb757ae3af4098c2514f24" type="hidden" name="infusion_xid" \/>\r\n<input id="infusion_type" value="CustomFormWeb" type="hidden" name="infusion_type" \/>\r\n<input id="infusion_name" value="Lefkoe Institute Sign Up Form" type="hidden" name="infusion_name" \/>\r\n<table>\r\n\r\n		<tr><td>First Name <\/td><td><table cellpadding="0px" cellspacing="0px" border="0px">\r\n<tr>\r\n<td><input id="Contact0FirstName" type="text" class="default-input" name="Contact0FirstName" size="15" \/><\/td>\r\n<\/tr>\r\n<\/table>\r\n<\/td><\/tr>\r\n		<tr><td>Email <\/td><td><table cellpadding="0px" cellspacing="0px" border="0px">\r\n<tr>\r\n<td><input id="Contact0Email" type="text" class="default-input" name="Contact0Email" size="15" \/><\/td>\r\n<\/tr>\r\n<\/table>\r\n<\/td><\/tr>\r\n	<tr align="center"><td colspan="2"><input id="Submit" value="Submit" type="submit" class="button np inf-button" name="Submit" \/><\/td><\/tr>\r\n<\/table>\r\n<\/form>\r\n');