We need a two stage PHP registration form

I need someone proficient in PHP to code a two-stage registration form for our subscription website.

I have attached PNG's of how we want the registration forms to look and all of the elements can be provided.

We need the registration forms to send the inputted information to an email address after the user clicks 'Checkout', this link will also lead to another page on our website. We would also like the registration forms to be integrated with Mailchimp.

The basic layout can be seen here: http://www.fictionbookclub.co.uk/sign-up/

Our website is Wordpress, any questions please ask below.