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value=\"2\">Intersex</option></select><br/> \n\n<input type=\"text\" name=\"guardian\" value=\"\" placeholder=\"Guardian Name\" /><br/> \n\n<input placeholder=\"Date Of Birth (ex 01-DEC-1963)\" type=\"text\" name=\"birth_date\" value=\"\" /><br/> \n<input type=\"text\" name=\"email\" value=\"\" placeholder=\"Email\" /><br/> \n<input type=\"text\" name=\"mobile_phone\" value=\"\" placeholder=\"Mobile Phone\"/><br/> \n\n            <label>Which Cortica Research location is most convenient?</label> \n            <select name=\"custom1\"> \n                <option value=\"\"></option> \n\n                <option value=\"San Rafael, California (Northern California)\">San Rafael, California (Northern California)</option><option value=\"Glendale, California (Southern California)\">Glendale, California (Southern California)</option><option value=\"I am not local but would be willing to travel (travel expenses are not reimbursed)\">I am not local but would be willing to travel (travel expenses 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