<!-- Begin MailChimp Signup Form --><!-- [et_pb_line_break_holder] --><link href="//cdn-images.mailchimp.com/embedcode/classic-10_7.css" rel="stylesheet" type="text/css"><!-- [et_pb_line_break_holder] --><style type="text/css"><!-- [et_pb_line_break_holder] --> #mc_embed_signup{background:#fff; clear:left; font:14px Helvetica,Arial,sans-serif; }<!-- [et_pb_line_break_holder] --> .indicates-required{float: left;}<!-- [et_pb_line_break_holder] --> div.mc-field-group.input-group{padding-bottom: 10px !important;}<!-- [et_pb_line_break_holder] --> /* Add your own MailChimp form style overrides in your site stylesheet or in this style block.<!-- [et_pb_line_break_holder] --> We recommend moving this block and the preceding CSS link to the HEAD of your HTML file. */<!-- [et_pb_line_break_holder] --></style><!-- [et_pb_line_break_holder] --><div id="mc_embed_signup"><!-- [et_pb_line_break_holder] --><form action="//byrontech.us15.list-manage.com/subscribe/post?u=b58b5815a96543d804cdab5f0&id=2c50981292" method="post" id="mc-embedded-subscribe-form" name="mc-embedded-subscribe-form" class="validate" target="_blank" novalidate><!-- [et_pb_line_break_holder] --> <div id="mc_embed_signup_scroll"><!-- [et_pb_line_break_holder] --> <h2>Headache School Registration - March 2017</h2><!-- [et_pb_line_break_holder] --> <p>Pre-Register for the Headache School courses you would like to attend.</p><br><br><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --><div class="mc-field-group input-group"><!-- [et_pb_line_break_holder] --> <strong><p>Headache School Courses</p></strong><!-- [et_pb_line_break_holder] --> <ul><li><input type="checkbox" value="1" name="group[879][1]" id="mce-group[879]-879-0"><label for="mce-group[879]-879-0">March 21 - Tai-Chi</label></li><!-- [et_pb_line_break_holder] --><li><input type="checkbox" value="2" name="group[879][2]" id="mce-group[879]-879-1"><label for="mce-group[879]-879-1">March 28 - Pain Management</label></li><!-- [et_pb_line_break_holder] --><li><input type="checkbox" value="4" name="group[879][4]" id="mce-group[879]-879-2"><label for="mce-group[879]-879-2">March 28 - Mindful Yoga</label></li><!-- [et_pb_line_break_holder] --></ul><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><div class="indicates-required"><span class="asterisk">*</span> indicates required</div><!-- [et_pb_line_break_holder] --><div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-EMAIL">Email Address <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <input type="email" value="" name="EMAIL" class="required email" id="mce-EMAIL"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-FNAME">First Name <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <input type="text" value="" name="FNAME" class="required" id="mce-FNAME"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-LNAME">Last Name <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <input type="text" value="" name="LNAME" class="required" id="mce-LNAME"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group size1of2"><!-- [et_pb_line_break_holder] --> <label for="mce-PHONE">Phone <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <input type="text" name="PHONE" class="required" value="" id="mce-PHONE"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-HPROVIDE">Headache Provider <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <input type="text" value="" name="HPROVIDE" class="required" id="mce-HPROVIDE"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <div id="mce-responses" class="clear"><!-- [et_pb_line_break_holder] --> <div class="response" id="mce-error-response" style="display:none"></div><!-- [et_pb_line_break_holder] --> <div class="response" id="mce-success-response" style="display:none"></div><!-- [et_pb_line_break_holder] --> </div> <!-- real people should not fill this in and expect good things - do not remove this or risk form bot signups--><!-- [et_pb_line_break_holder] --> <div style="position: absolute; left: -5000px;" aria-hidden="true"><input type="text" name="b_b58b5815a96543d804cdab5f0_2c50981292" tabindex="-1" value=""></div><!-- [et_pb_line_break_holder] --> <div class="clear"><input type="submit" value="Sign Up" name="subscribe" id="mc-embedded-subscribe" class="button"></div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --></form><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><script type='text/javascript' src='//s3.amazonaws.com/downloads.mailchimp.com/js/mc-validate.js'></script><script type='text/javascript'>(function($) {window.fnames = new Array(); window.ftypes = new Array();fnames[0]='EMAIL';ftypes[0]='email';fnames[1]='FNAME';ftypes[1]='text';fnames[2]='LNAME';ftypes[2]='text';fnames[3]='PHONE';ftypes[3]='phone';fnames[4]='HPROVIDE';ftypes[4]='text';}(jQuery));var $mcj = jQuery.noConflict(true);</script><!-- [et_pb_line_break_holder] --><!--End mc_embed_signup-->