<!--Begin CTCT Sign-Up Form--><!-- [et_pb_line_break_holder] --><!-- EFD 1.0.0 [Mon Oct 19 17:33:47 EDT 2015] --><!-- [et_pb_line_break_holder] --><link rel='stylesheet' type='text/css' href='https://static.ctctcdn.com/h/contacts-embedded-signup-assets/1.0.2/css/signup-form.css'><!-- [et_pb_line_break_holder] --><div class="ctct-embed-signup" style="font-family: 'Open Sans', sans-serif;"><!-- [et_pb_line_break_holder] --> <span id="success_message" style="display:none;"><!-- [et_pb_line_break_holder] --> <div style="text-align:center;">Thanks for signing up!</div><!-- [et_pb_line_break_holder] --> </span><!-- [et_pb_line_break_holder] --> <form data-id="embedded_signup:form" class="ctct-custom-form Form" name="embedded_signup" method="POST" action="https://visitor2.constantcontact.com/api/signup"><!-- [et_pb_line_break_holder] --> <h2 style="margin:0;">Sign up to stay in touch!</h2><!-- [et_pb_line_break_holder] --> <p>Thank you for subscribing to our Heartland Family Service emails. <!-- [et_pb_line_break_holder] -->You will receive our monthly eNews and information about our events, and activities. </p><!-- [et_pb_line_break_holder] --> <!-- The following code must be included to ensure your sign-up form works properly. --><!-- [et_pb_line_break_holder] --> <input data-id="ca:input" name="ca" value="8badbdae-45b1-4751-ad4d-6d5072f75bec" type="hidden"><!-- [et_pb_line_break_holder] --> <input data-id="source:input" name="source" value="EFD" type="hidden"><!-- [et_pb_line_break_holder] --> <input data-id="required:input" name="required" value="list,email,first_name,last_name" type="hidden"><!-- [et_pb_line_break_holder] --> <input data-id="url:input" name="url" value="" type="hidden"><!-- [et_pb_line_break_holder] --> <p data-id="Email Address:p" ><label data-id="Email Address:label" data-name="email" class="ctct-form-required">Email Address</label> <input data-id="Email Address:input" name="email" value="" maxlength="80" type="text"></p><!-- [et_pb_line_break_holder] --> <p data-id="First Name:p" ><label class="ctct-form-required" data-id="First Name:label" data-name="first_name">First Name</label> <input data-id="First Name:input" name="first_name" value="" maxlength="50" type="text"></p><!-- [et_pb_line_break_holder] --> <p data-id="Last Name:p" ><label class="ctct-form-required" data-id="Last Name:label" data-name="last_name">Last Name</label> <input data-id="Last Name:input" name="last_name" value="" maxlength="50" type="text"></p><!-- [et_pb_line_break_holder] --> <p data-id="Phone Number:p" ><label data-id="Phone Number:label" data-name="phone">Phone Number</label> <input data-id="Phone Number:input" name="phone" value="" maxlength="50" type="text"></p><!-- [et_pb_line_break_holder] --> <p data-id="Street Address:p" ><label data-id="Street Address:label" data-name="address_street">Street</label> <input data-id="Street Address:input" name="address_street" value="" maxlength="50" type="text"></p><!-- [et_pb_line_break_holder] --> <p data-id="City:p" ><label data-id="City:label" data-name="address_city">City</label> <input data-id="City:input" name="address_city" value="" maxlength="50" type="text"></p><!-- [et_pb_line_break_holder] --> <p data-id="State/Province:p" ><label data-id="State/Province:label" data-name="address_state">Select a state/province</label></p><!-- [et_pb_line_break_holder] --> <p data-id="Zip Code:p" ><label data-id="Zip Code:label" data-name="address_postal_code">Zip Code</label> <input data-id="Zip Code:input" name="address_postal_code" value="" maxlength="50" type="text"></p><!-- [et_pb_line_break_holder] --> <p data-id="Lists:p" ><label data-id="Lists:label" data-name="list" class="ctct-form-required">Email Lists</label><div><input data-id="Lists:input" name="list_0" value="64" type="checkbox"><span data-id="Lists:span">Heartland Family Service Events</span></div><div><input data-id="Lists:input" name="list_1" value="1" type="checkbox"><span data-id="Lists:span">Heartland Family Service News</span></div></p><!-- [et_pb_line_break_holder] --> <button type="submit" class="Button ctct-button Button--block Button-secondary" data-enabled="enabled">Sign Up</button><!-- [et_pb_line_break_holder] --> <div><p class="ctct-form-footer">By submitting this form, you are granting: Heartland Family Service, More than 15 Locations, Omaha, Nebraska, 68105, United States, https://www.heartlandfamilyservice.org permission to email you. You may unsubscribe via the link found at the bottom of every email. (See our <a href="http://www.constantcontact.com/legal/privacy-statement" target="_blank">Email Privacy Policy</a> for details.) Emails are serviced by Constant Contact.</p></div><!-- [et_pb_line_break_holder] --> </form><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><script type='text/javascript'><!-- [et_pb_line_break_holder] --> var localizedErrMap = {};<!-- [et_pb_line_break_holder] --> localizedErrMap['required'] = 'This field is required.';<!-- [et_pb_line_break_holder] --> localizedErrMap['ca'] = 'An unexpected error occurred while attempting to send email.';<!-- [et_pb_line_break_holder] --> localizedErrMap['email'] = 'Please enter your email address in name@email.com format.';<!-- [et_pb_line_break_holder] --> localizedErrMap['birthday'] = 'Please enter birthday in MM/DD format.';<!-- [et_pb_line_break_holder] --> localizedErrMap['anniversary'] = 'Please enter anniversary in MM/DD/YYYY format.';<!-- [et_pb_line_break_holder] --> localizedErrMap['custom_date'] = 'Please enter this date in MM/DD/YYYY format.';<!-- [et_pb_line_break_holder] --> localizedErrMap['list'] = 'Please select at least one email list.';<!-- [et_pb_line_break_holder] --> localizedErrMap['generic'] = 'This field is invalid.';<!-- [et_pb_line_break_holder] --> localizedErrMap['shared'] = 'Sorry, we could not complete your sign-up. Please contact us to resolve this.';<!-- [et_pb_line_break_holder] --> localizedErrMap['state_mismatch'] = 'Mismatched State/Province and Country.';<!-- [et_pb_line_break_holder] --> localizedErrMap['state_province'] = 'Select a state/province';<!-- [et_pb_line_break_holder] --> localizedErrMap['selectcountry'] = 'Select a country';<!-- [et_pb_line_break_holder] --> var postURL = 'https://visitor2.constantcontact.com/api/signup';<!-- [et_pb_line_break_holder] --></script><!-- [et_pb_line_break_holder] --><script type='text/javascript' src='https://static.ctctcdn.com/h/contacts-embedded-signup-assets/1.0.2/js/signup-form.js'></script><!-- [et_pb_line_break_holder] --><!--End CTCT Sign-Up Form--><!-- [et_pb_line_break_holder] -->