Can't get mailchimp embedded form code to render in wpchimp countdown theme

Hello, I’ve installed this theme:
http://wpchimp.com/b/wpchimp-countdown-theme/

When you go and customize the theme, there is a text box where you can enter “Signup form HTML”.

I’ve pasted the signup form html that was generated by mailchimp, but it doesn’t render correctly.

There are no feilds visible (for people to enter email addresses) and no buttons (to click submit).

Here is the code generated by mailchimp (with the part specific to my site redacted). It works when I try and embed it in a page or post using the “Text” version of the editor.

I’ve taken a screenshot of what it looks like if I try to put it on the landing page using the customize theme window:
http://imgur.com/JmkfGZ6

<!-- Begin MailChimp Signup Form -->
<div id="mc_embed_signup">
<form action="" method="post" id="mc-embedded-subscribe-form" name="mc-embedded-subscribe-form" class="validate" target="_blank" novalidate>

<div class="mc-field-group">
	<label for="mce-EMAIL">Email Address </label>
	<input type="email" value="" name="EMAIL" class="required email" id="mce-EMAIL">
</div>
<div class="mc-field-group">
	<label for="mce-FNAME">First Name </label>
	<input type="text" value="" name="FNAME" class="required" id="mce-FNAME">
</div>
	<div id="mce-responses">
		<div class="response" id="mce-error-response" style="display:none"></div>
		<div class="response" id="mce-success-response" style="display:none"></div>
	</div>    <!-- real people should not fill this in and expect good things - do not remove this or risk form bot signups-->
    <div style="position: absolute; left: -5000px;"><input type="text" name="b_c64ed0c42d042e379d593aa7e_a21a54924e" tabindex="-1" value=""></div>
    <div><input type="submit" value="Subscribe" name="subscribe" id="mc-embedded-subscribe" class="button"></div>
</form>
</div>

<!--End mc_embed_signup-->