document.write('<style type="text/css">\r\n<!--\r\n   #webFrmID { font-family: "Lucida Sans Unicode", "Lucida Grande", sans-serif; font-size: 12px; color: #666;  }\r\n   #webFrmID .cntBox { position: relative; left: 50%; width: auto; float: left; clear: both; text-align: left; margin: 5px 0 12px 0; }\r\n   #webFrmID .cntBox .box { position: relative; left: -50%; float: left; padding: 0; }\r\n  #webFrmID .chikLet { margin: 0 0 5px 0; padding: 0; height: 24px; }\r\n  #webFrmID .chikLet li, .chikLet li span { background: url(http://www.getresponse.com/images/core/icons/gr_chicklet.png) left top no-repeat; display: block; height: 24px; }\r\n  #webFrmID .chikLet li { margin: 0; padding: 0 0 0 24px; float: left; line-height: 24px; }\r\n  #webFrmID .chikLet li span { background-position: right bottom; padding: 0 8px 0 4px; float: left; }\r\n  #webFrmID .clearer { width: 100%; height: 0.1px; font-size: 0.1px; clear: both; line-height: 0.1px; }\r\n-->\r\n</style>\r\n<div id="webFrmID"> \r\n<form accept-charset="utf-8" action="http://www.getresponse.com/cgi-bin/add.cgi" style="width: 250px; font-family: verdana; background-color: #ffffff; margin: 5px;"><input type="hidden" name="custom_http_referer" id="custom_http_referer" value=""/>\r\n    <div id="webform_title" style="line-height:21px; padding: 7px 20px 7px 20px; font-size: 21px; color: #ffffff; background-color: #278DE2; border: 1px solid #278DE2;">\r\n    Report\r\n    </div>\r\n    <div style="font-family: tahoma; border: 1px solid #DEDEDE;">\r\n        <div style="font-size: 12px; color: #4C4B4B; padding: 16px; padding-bottom: 12px;">\r\n        \r\n        </div>\r\n        <hr style="height: 1px; border: 0; background-color: #F0F0F0; color: #F0F0F0; margin: 0 20px 0 20px;"/>\r\n        <ul id="fields" style="list-style: none; margin: 0; font-size: 12px; color: #7B7B7B; padding: 15px 30px 15px 30px;">\r\n        <li id="subscriber_name-field" style="padding: 4px 0 5px 0; margin: 0; background: none; width: 100%;">\r\n    <label style="float: left;" for="subscriber_name">Name :</label>\r\n    <input style="float: right; border: 1px solid #AEB186; width: 140px;" id="subscriber_name" name="subscriber_name" type="text" value=""/>\r\n    <div style="clear: both;"/>\r\n</li>\r\n<li id="subscriber_email-field" style="padding: 4px 0 5px 0; margin: 0; background: none; width: 100%;">\r\n    <label style="float: left;" for="subscriber_email">Email :</label>\r\n    <input style="float: right; border: 1px solid #AEB186; width: 140px;" id="subscriber_email" name="subscriber_email" type="text" value=""/>\r\n    <div style="clear: both;"/>\r\n</li>\r\n<li id="custom_School-field" style="padding: 4px 0 5px 0; margin: 0; background: none; width: 100%;">\r\n    <label style="float: left;" for="custom_School">School :</label>\r\n    <input style="float: right; border: 1px solid #AEB186; width: 140px;" id="custom_School" name="custom_School" type="text" value=""/>\r\n    <div style="clear: both;"/>\r\n</li>\r\n\r\n        </ul>\r\n        <ul style="list-style: none; margin: 0; font-size: 12px; color: #7B7B7B; padding: 15px 30px 15px 30px; text-align: center;">\r\n        \r\n        </ul>\r\n        <input type="hidden" name="confirmation_url" id="confirmation_url" value=""/>\r\n        <input type="hidden" name="error_url" id="error_url" value=""/>\r\n        <input type="hidden" name="campaign_name" id="campaign_name" value="hsgradparty"/>\r\n        <input type="hidden" name="custom_ref" id="custom_ref" value=""/>            <hr style="height: 1px; border: 0; background-color: #F0F0F0; color: #F0F0F0; margin: 0 20px 0 20px;"/>\r\n        <div style="text-align: center; padding-bottom: 18px; padding-top: 10px">\r\n            <input id="webform_submit" style="cursor: hand; font-family: verdana; font-size: 18px; color: #FFFFFF; background-image: url(http://www.getresponse.com/images/common/templates/webforms/grey_button.png); border: 0; width: 140px; height: 33px; margin: 10px;" type="submit" value="Request"/>\r\n            \r\n            \r\n            <div class="clearer"></div>\r\n        </div>\r\n    </div>\r\n</form>\r\n</div>\r\n<script type="text/javascript">var el=document.getElementById("custom_http_referer");if(el != null){el.value = document.location};</script>');