<div class="brz-forms__fields css-10cwydl">
<div class="fw-col-sm-6" style="padding-bottom: 20px;">[text* your-name placeholder "Enter Full Name"]</div>

<div class="fw-col-sm-6" style="padding-bottom: 20px;">[tel* phone-number placeholder "Enter your Phone Number"]</div>

<div class="fw-col-sm-6" style="padding-bottom: 20px;">[email* email placeholder "Enter your Email ID"]</div>

<div class="fw-col-sm-6" style="padding-bottom: 20px;">
[select* selection first_as_label "You are a:" "Parent" "Donor" "Volunteer" "Media Personnel" "Audiologist" "AV Therapist" "Special Educator" "Teacher" "Other"]</div>

<div class="fw-col-sm-12" style="padding-bottom: 20px;">
[group select-other]
[text* other placeholder "Enter your Profession"]
[/group]</div>

Select Language:<br />
[select* language multiple "English" "Hindi"]
[group g1]English Self Advocacy Cards will be emailed to you[/group]
[group g2]Hindi Self Advocacy Cards will be emailed to you[/group]

<div class="fw-col-sm-12">
[submit class:vconnect-submit "Download"]</div></div>