<p>Your Name (required)<br />
    [text* FirstName] </p>

<p>Your Last Name (required)<br />
    [text* LastName] </p>

<p>Country<br />
    [text Country] </p>

<p>Your Email (required)<br />
    [email* Email] </p>

<p>Prayer Request Is For<br />
    [text PrayerRequestIsFor] </p>

<p>Your Message (required)<br />
   [textarea Message] </p>

<p>[submit "Send"]</p>