<div id="mc_embed_signup" class="col-md-6">
<form action="https://nacda-aging.us20.list-manage.com/subscribe?u=e3217e25f4145ba62ec0fca3b&id=355ad440b3" method="post" id="mc-embedded-subscribe-form" name="mc-embedded-subscribe-form" class="validate" target="_blank" novalidate="novalidate">
<div id="mc_embed_signup_scroll">
<div class="indicates-required mb-3">
<span class="text-danger">*</span> indicates required field
</div>
<div class="mc-field-group mb-3">
<label class="form-label" for="mce-EMAIL">Email Address  <span class="text-danger">*</span></label><br />
<input type="email" value="" name="EMAIL" class="required email form-control" id="mce-EMAIL" aria-required="true" autocomplete="off">
</div>
<div class="mc-field-group mb-3">
<label class="form-label" for="mce-FNAME">First Name </label><br />
<input type="text" value="" name="FNAME" class="form-control" id="mce-FNAME">
</div>
<div class="mc-field-group mb-3">
<label class="form-label" for="mce-LNAME">Last Name </label><br />
<input type="text" value="" name="LNAME" class="form-control" id="mce-LNAME">
</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>
</p>
</div>
<p>    </p>
<div class="d-none invisible" aria-hidden="true"><input type="text" name="b_93d3960406f5fb4f5098f1bb6_a2cda39a16" tabindex="-1" value=""></div>
<div class="clear"><input type="submit" value="Subscribe" name="subscribe" id="mc-embedded-subscribe" class="btn btn-primary"></div>
</p>
</div>
</form>
</div>

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