Senior Services BU > Cloud Pages > API Internal Testing Forms > Senior Services Dementia Program - TEST FORM


      <h2>Senior Services Dementia Program - Test Form</h2>
      <form action="https://pages.upmc.com/senior-services-dementia-program-api-internal-testing-form" method="post">
         <label>Email</label>
         <input type="text" name="email_address"><br>
         <label>First Name</label>
         <input type="text" name="first_name"><br>
         <label>Last Name</label>
         <input type="text" name="last_name"><br>
         <label>Phone Number</label>
         <input type="text" name="phone_number"><br>
         <label>Street Address 1</label>
         <input type="text" name="street_address_1"><br>
         <label>Street Address 2</label>
         <input type="text" name="street_address_2"><br>
         <label>City</label>
         <input type="text" name="city"><br>
         <label>State</label>
         <input type="text" name="state"><br>
         <label>Zip Code</label>
         <input type="text" name="zip_code"><br>
         <label>Organization Name</label>
         <input type="text" name="organization_name"><br><br>
         <label>What best describes you?</label>
         <select name="personal_description" id="personal_description">
            <option value="" selected="selected">Select One</option>
            <option value="Informal caregiver (family, friend, neighbor)">Informal caregiver (family, friend, neighbor)</option>
            <option value="Formal caregiver (professional)">Formal caregiver (professional)</option>
            <option value="Intergenerational champion (young adult - 18 years of age or older)">Intergenerational champion (young adult - 18 years of age or older)</option>
            <option value="Other">Other</option>
         </select><br><br>
         
         <label>Service Line</label>
         <input type="text" name="service_line"><br><br>
         <label>Category</label>
         <input type="text" name="category"><br>
         <label>Subcategory</label>
         <input type="text" name="subcategory"><br>
         <input name="submitted" type="hidden" value="true" />
         <input type="submit" value="Submit">
      </form>