document.write("<!-- Web Form Generator 2.0 --><center><form method=\"post\" action=\"http://www.aweber.com/scripts/addlead.pl\" target=\"_new\"><input type=\"hidden\" name=\"meta_web_form_id\" value=\"1410556041\"><input type=\"hidden\" name=\"meta_split_id\" value=\"\"><input type=\"hidden\" name=\"unit\" value=\"drdebmain\"><input type=\"hidden\" name=\"redirect\" value=\"http://www.y2khealthanddetox.com/thankyou-children.html\" id=\"redirect_22304141413f667219428c5484b4691e\"><input type=\"hidden\" name=\"meta_redirect_onlist\" value=\"\"><input type=\"hidden\" name=\"meta_adtracking\" value=\"\"><input type=\"hidden\" name=\"meta_message\" value=\"6\"><input type=\"hidden\" name=\"meta_required\" value=\"from\"><input type=\"hidden\" name=\"meta_forward_vars\" value=\"0\"><table><tr><td colspan=2><center><div align=\"center\">Help&nbsp;Me To Find What You'd Like To See In My Upcoming Book<br /><font color=\"#cc0000\"><strong>Children's Health - The Way Nature Intended.<br /></strong></font>Thanx!<br /><br /><span></span>Make Sure Your Email is Correct..That is Where I'll Send Your <em><strong>Free </strong></em>Copy!&nbsp;</div></center></td></tr><tr><td>Email:</td><td><input type=\"text\" name=\"from\" value=\"\" size=\"20\"></td></tr><tr><td>Name:</td><td><input type=\"text\" name=\"name\" value=\"\" size=\"20\"></td></tr><tr><td>What are the biggest concerns about your childrens health:</td><td><input type=\"text\" name=\"custom What are the biggest concerns about your childrens health\" value=\"\" size=\"20\"></td></tr><tr><td>continue:</td><td><input type=\"text\" name=\"custom continue\" value=\"\" size=\"20\"></td></tr><tr><td>continue again:</td><td><input type=\"text\" name=\"custom continue again\" value=\"\" size=\"20\"></td></tr><tr><td>Do you deal with asthma:</td><td><input type=\"text\" name=\"custom Do you deal with asthma\" value=\"\" size=\"20\"></td></tr><tr><td>Frequent colds-coughs-ear infections:</td><td><input type=\"text\" name=\"custom Frequent colds-coughs-ear infections\" value=\"\" size=\"20\"></td></tr><tr><td>Allergies:</td><td><input type=\"text\" name=\"custom Allergies\" value=\"\" size=\"20\"></td></tr><tr><td>Vaccination issues:</td><td><input type=\"text\" name=\"custom Vaccination issues\" value=\"\" size=\"20\"></td></tr><tr><td>Breastfeeding-Nursing Problems:</td><td><input type=\"text\" name=\"custom Breastfeeding-Nursing Problems\" value=\"\" size=\"20\"></td></tr><tr><td>Do you think your child has a weak immune system:</td><td><input type=\"text\" name=\"custom Do you think your child has a weak immune system\" value=\"\" size=\"20\"></td></tr><tr><td>Any serious or chronic illnesses-Autism ADHD Diabetes etc:</td><td><input type=\"text\" name=\"custom Any serious or chronic illnesses\" value=\"\" size=\"20\"></td></tr><tr><td>Do you wish a drug free approach for your child:</td><td><input type=\"text\" name=\"custom Do you wish a drug free approach for your child\" value=\"\" size=\"20\"></td></tr>    <tr><td colspan=2><center></center></td></tr><tr><td align=\"center\" colspan=\"2\"><input type=\"submit\" name=\"submit\" value=\"Submit\"></td></tr></table></form></center>");

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