This should be a faculty advisor pop-up form with fields to fill out, and two buttons "submit" and "cancel".
The top of the form says

Enter information below if you are interested in being a FENGA chapter faculty advisor

The pop-up form collects the following information:

When the user clicks "Submit" the email address is checked for the right format (e.g., must contain an asterisk). If the email address is bad, an error message is shown and the form does not close. If the email address is acceptable, and the checkbox is checked, the form information is stored in a database with a timestamp, and the contents of the form are sent to the email address: