connect.chamberlain.edu Open in urlscan Pro
130.35.18.0  Public Scan

Form analysis
1 forms found in the DOM

Name: InquiryNurtureContactYourAdvisor — POST https://connect.chamberlain.edu/e/f2

<form method="post" name="InquiryNurtureContactYourAdvisor" action="https://connect.chamberlain.edu/e/f2"
  onsubmit="setTimeout(function(){if(document.querySelector){var s=document.querySelector('form#form26 input[type=submit]');if(s){s.disabled=true;}}},100);return true;" id="form26" class="elq-form">
  <input value="InquiryNurtureContactYourAdvisor" type="hidden" name="elqFormName">
  <input value="125869073" type="hidden" name="elqSiteId">
  <input name="derivedAdvisorName" type="hidden" value="Chamberlain College of Nursing">
  <input name="advisorEmail" type="hidden" value="cuadmissions@chamberlain.edu">
  <input name="status" type="hidden" value="">
  <input name="location" type="hidden" value="">
  <div class="survey-box" style="width:900px;margin:0 auto;">
    <div><span style="font-size:12px;line-height:14px;"><span style="color: red !important; display: inline; float: none; font-weight: bold; margin: 0pt 0pt 0pt; padding: 0pt 0pt 0pt"> * </span>Denotes a required field</span></div>
    <div class="field-box" style="display:inline-block;width:43%;padding-right:10px;">
      <label class="survey-checkbox" style="color: #013a81;font-family: Proxima Nova, Arial, sans-serif;font-size: 16px;font-weight: 700;">First Name<span
          style="color: red !important; display: inline; float: none; font-weight: bold; margin: 0pt 0pt 0pt; padding: 0pt 0pt 0pt"> * </span></label>
      <input type="text" class="survey-checkbox" name="firstName" style="margin:10px 10px 25px !important;" value="" id="field0">
    </div>
    <div class="field-box" style="display:inline-block;width:43%;padding-right:10px;">
      <label class="survey-checkbox" style="color: #013a81;font-family: Proxima Nova, Arial, sans-serif;font-size: 16px;font-weight: 700;">Last Name<span
          style="color: red !important; display: inline; float: none; font-weight: bold; margin: 0pt 0pt 0pt; padding: 0pt 0pt 0pt"> * </span></label>
      <input type="text" class="survey-checkbox" name="lastName" style="margin:10px 10px 25px !important;" value="" id="field1">
    </div>
    <div class="field-box" style="display:inline-block;width:43%;padding-right:10px;">
      <label class="survey-checkbox" style="color: #013a81;font-family: Proxima Nova, Arial, sans-serif;font-size: 16px;font-weight: 700;">Email Address<span
          style="color: red !important; display: inline; float: none; font-weight: bold; margin: 0pt 0pt 0pt; padding: 0pt 0pt 0pt"> * </span></label>
      <input type="text" class="survey-checkbox" name="email" style="margin:10px 10px 25px !important;" value="" id="field2">
    </div>
    <div class="field-box" style="display:inline-block;width:43%;padding-right:10px;">
      <label class="survey-checkbox" style="color: #013a81;font-family: Proxima Nova, Arial, sans-serif;font-size: 16px;font-weight: 700;">Phone Number<span
          style="color: red !important; display: inline; float: none; font-weight: bold; margin: 0pt 0pt 0pt; padding: 0pt 0pt 0pt"> * </span></label>
      <input type="text" class="survey-checkbox" name="phone" style="margin:10px 10px 25px !important;" value="" id="field3">
    </div>
    <div class="field-box contact-you" style="display:block;width:30%;padding-right:10px;">
      <label class="survey-checkbox" style="color: #013a81;font-family: Proxima Nova, Arial, sans-serif;font-size: 16px;font-weight: 700;;">Best Time to Contact You<span
          style="color: red !important; display: inline; float: none; font-weight: bold; margin: 0pt 0pt 0pt; padding: 0pt 0pt 0pt"> * </span></label>
      <select type="text" class="survey-checkbox" name="bestTimetoContact" style="margin:10px 10px 25px !important;" value="" id="field4">
        <option value="">Select One</option>
        <option value="Morning">Morning</option>
        <option value="Afternoon">Afternoon</option>
        <option value="Evening">Evening</option>
      </select>
    </div>
    <div class="field-box" style="display:block;width:86%;padding-right:10px;">
      <label class="survey-checkbox" style="color: #013a81;font-family: Proxima Nova, Arial, sans-serif;font-size: 16px;font-weight: 700;;">Note to Admission Representative</label>
      <textarea class="survey-checkbox" name="note" style="margin:10px 10px 25px !important;" value="" id="field11" rows="4"></textarea>
    </div>
  </div>
  <div class="submit-box" style="width:900px;margin:0 auto;">
    <input type="submit" value="Submit" class="submit-button" style="line-height: 27px;">
    <div class="copy-container" style="padding-bottom:15px;">
      <p style="font-size:12px;line-height:14px;">By submitting this form, I provide my signature, expressly consenting to calls, emails and/or texts regarding my educational options from Chamberlain College of Nursing and its affiliates and
        contractors using an automated dialing system to the number and email address provided. I understand my consent is not required to enroll at Chamberlain, and that I can withdraw my consent at any time.</p>
    </div>
  </div>
</form>

Text Content

* Denotes a required field
First Name *
Last Name *
Email Address *
Phone Number *
Best Time to Contact You * Select One Morning Afternoon Evening
Note to Admission Representative

By submitting this form, I provide my signature, expressly consenting to calls,
emails and/or texts regarding my educational options from Chamberlain College of
Nursing and its affiliates and contractors using an automated dialing system to
the number and email address provided. I understand my consent is not required
to enroll at Chamberlain, and that I can withdraw my consent at any time.