This should be a parent 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 a parent interested in how FENGA can support your child's interest in STEM

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, the form information is stored in a database with a timestamp, and the contents of the form are sent to the email address: