<p>Name (required)<br />
    [text* name] </p>

<p>Address (required)<br />
    [text* address] </p>

<p>City (required)<br />
    [text* city] </p>

<p>State <br/>[select* menu-states include_blank "Alabama" "Alaska" "Arizona" "Arkansas" "California" "Colorado" "Connecticut" "Delaware" "District of Columbia" "Florida" "Georgia" "Hawaii" "Idaho" "Illinois" "Indiana" "Iowa" "Kansas" "Kentucky" "Louisiana" "Maine" "Maryland" "Massachusetts" "Michigan" "Minnesota" "Mississippi" "Missouri" "Montana" "Nebraska" "Nevada" "New Hampshire" "New Jersey" "New Mexico" "New York" "North Carolina" "North Dakota" "Ohio" "Oklahoma" "Oregon" "Pennsylvania" "Rhode Island" "South Carolina" "South Dakota" "Tennessee" "Texas" "Utah" "Vermont" "Virginia" "Washington" "West Virginia" "Wisconsin" "Wyoming"] 

<p>Zip Code (required)<br />
    [text* zip-code] </p>

<p>Member Since <br />
    [text member-since] </p>

<p>Your Email (required)<br />
    [email* email] </p>

<p>Please share with us your interests in, and concerns for, the Lower Garden District: What do you love about the ‘hood? What do you dislike? Why do you live here? What can we do to make it better? The more specific your reply, the better we may be able to help! <br/>
    [textarea message] </p>

<p>[submit "Send"]</p>