Widget:PHPListSubscribe

<form method=post name="subscribeform" action="http://www.mhlo.org.uk/lists/?p=subscribe&id=1">

<fieldset>

   <legend>Required information</legend>

   <label>Email (required): 
   <input class="small-10 columns" type="text" name="email" value=""></label>

   <label>Confirm your email address (required): 
   <input class="small-10 columns" type="text" name="emailconfirm" value=""></label>

</fieldset>

<fieldset>

   <legend>Optional information</legend>

   <label>Christian name:
   <input type="text" name="attribute1"  value=""></label>

   <label>Surname: 
   <input type="text" name="attribute4"  value=""></label>

   <label>Reason for interest in MH law:
   <input type="text" name="attribute3"  value=""></label>

</fieldset>

<fieldset>

 <legend>Please select the newsletters you want to sign up to:</legend>

   <input type="checkbox" name="list[2]" value=signup checked />

News: Occasional updates to the site (sent when cases, legislation etc are added)

   <input type="checkbox" name="list[3]" value=signup checked />

Monthly update: A monthly summary of additions to the site (fewer emails than the other list, but you can subscribe to both lists)

</fieldset>

 <input type="hidden" name="htmlemail" value="1" />

<input type=submit name="subscribe" value="Subscribe">