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<div id="mc_embed_signup">
<form action="https://wellnessbyalex.us17.list-manage.com/subscribe/post?u=8038fac947086ad016da5d7d0&id=d336d431fa" method="post" id="mc-embedded-subscribe-form" name="mc-embedded-subscribe-form" class="validate" target="_blank" novalidate>
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<div class="mc-field-group">
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<div class="mc-field-group">
	<label for="mce-FNAME">First Name </label>
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<div class="mc-field-group">
	<label for="mce-LNAME">Last Name </label>
	<input type="text" value="" name="LNAME" class="" id="mce-LNAME">
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<div class="mc-field-group size1of2">
	<label for="mce-BIRTHDAY-month">Birthday </label>
	<div class="datefield">
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		<span class="subfield dayfield"><input class="birthday " type="text" pattern="[0-9]*" value="" placeholder="DD" size="2" maxlength="2" name="BIRTHDAY[day]" id="mce-BIRTHDAY-day"></span> 
		<span class="small-meta nowrap">( mm / dd )</span>
	</div>
</div>	<div id="mce-responses" class="clear">
		<div class="response" id="mce-error-response" style="display:none"></div>
		<div class="response" id="mce-success-response" style="display:none"></div>
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    <div style="position: absolute; left: -5000px;" aria-hidden="true"><input type="text" name="b_8038fac947086ad016da5d7d0_d336d431fa" tabindex="-1" value=""></div>
    <div class="clear"><input type="submit" value="Subscribe" name="subscribe" id="mc-embedded-subscribe" class="button"></div>
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</form>
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<script type='text/javascript' src='//s3.amazonaws.com/downloads.mailchimp.com/js/mc-validate.js'></script><script type='text/javascript'>(function($) {window.fnames = new Array(); window.ftypes = new Array();fnames[0]='EMAIL';ftypes[0]='email';fnames[1]='FNAME';ftypes[1]='text';fnames[2]='LNAME';ftypes[2]='text';fnames[3]='BIRTHDAY';ftypes[3]='birthday';}(jQuery));var $mcj = jQuery.noConflict(true);</script>

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