<div class="c-form__fieldset">
<div class="grid">
<div class="c-form__col col-12">
<label for="stemi-select">What can we help you with? </label><div class="custom-select">[select* the-subject default:get id:stemi-select include_blank "I want a callback" "I want to book a demo of your product" "I'm interested in using your educational platform" "I'm interested in distributing your programs" "I want to donate programs to schools" "I'm interested in STEM program development collaboration" "I'm interested in implementing scalable social impact project" "I need technical support" "Other"]</div>
</div>
</div>
</div>
<div class="c-form__fieldset">
<div class="grid">
<div class="c-form__col col-6_lt-12">
<label for="first-name">First name* </label>[text* first-name class:c-form__input id:first-name]
</div>
<div class="c-form__col col-6_lt-12">
<label for="last-name">Last name* </label>[text* last-name class:c-form__input id:last-name]
</div>
</div>
</div>
<div class="c-form__fieldset">
<div class="grid">
<div class="c-form__col col-6_lt-12">
<label for="email">Email* </label>[email* email class:c-form__input id:email]
</div>
<div class="c-form__col col-6_lt-12">
<label for="phone-number">Phone number* </label>[tel* phone-number class:c-form__input id:phone-number]
</div>
</div>
</div>
<div class="c-form__fieldset">
<div class="grid">
<div class="c-form__col col-6_lt-12">
<label for="city">City* </label>[text* city class:c-form__input id:city]
</div>
<div class="c-form__col col-6_lt-12">
<label for="organization">Organization* </label>[text* organization class:c-form__input id:organization]
</div>
</div>
</div>
<div class="c-form__fieldset">
<div class="grid">
<div class="col-12">
<label for="message"> Message* </label>[textarea* your-message class:c-form__input class:c-form__input--textarea id:message]
</div>
</div>
</div>
<div class="c-form__fieldset c-form__fieldset--checkbox">
[checkbox checkbox-540 use_label_element "I would like to get occasional informational emails from STEMI"]
</div>
<div class="c-form__fieldset">
<div class="cta-wrapper cta-wrapper--blue-light"><button type="submit" class="wpcf7-form-control wpcf7-submit btn btn-primary cta">SEND</button</div>
</div>
[popup]