--- /dev/null
+{{include file="field_input.tpl" field=$baseurl}}
+{{include file="field_input.tpl" field=$siteid}}
+{{include file="field_checkbox.tpl" field=$optout}}
+{{include file="field_checkbox.tpl" field=$async}}
+<div class="submit"><input type="submit" name="page_site" value="{{$submit}}" /></div>