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  1. <!DOCTYPE html>
  2. <!--
  3. To change this license header, choose License Headers in Project Properties.
  4. To change this template file, choose Tools | Templates
  5. and open the template in the editor.
  6. -->
  7. <html>
  8.     <head>
  9.         <meta charset="UTF-8">
  10.         <title>Volunteer Database</title>
  11.         <script type="text/javascript" src="js/functions.js"> </script>
  12.         <link rel="stylesheet" href="css/bootstrap-theme.css" type="text/css" />
  13.         <link rel="stylesheet" href="css/bootstrap.css" type="text/css" />
  14.     </head>
  15.     <body>
  16.         <br><br><br>
  17.         <form action="update.php" method="post">
  18.         <center><table style="border:1px solid black; width:850px; padding:2px;">
  19.            <tr>
  20.                <td><label>First Name:</label></td><td><input type="text" name="fname" id="fname" /></td>
  21.            <td><label>Middle Initial:</label></td><td><input type="text" name="middle" id="middle" /></td>
  22.            <td><label>Last Name:</label></td><td><input type="text" name="lname" id="lname" /></td></tr>
  23.             <tr><td><label>Street Address:</label></td><td colspan="3"><input type="text" name="address" id="address" style="width:320px;" /></td>
  24.             <td><label>City:</label></td><td><input type="text" name="city" id="city" /></td></tr>
  25.             <tr><td><label>State:</label></td><td><input type="text" name="state" id="state" /></td>
  26.                 <td><label>ZIP:</label></td><td><input type="text" name="zip" id="zip" /></td>
  27.                 <td><label>County:</label></td><td><select name="county" id="county"><option>Butler</option><option>Cass</option><option>Fillmore</option><option>Gage</option><option>Jefferson</option><option>Johnson</option><option>Lancaster</option><option>Nemaha</option><option>Otoe</option><option>Pawnee</option><option>Polk</option><option>Richardson</option><option>Saline</option><option>Saunders</option><option>Seward</option><option>Thayer</option><option>York</option></select></td></tr>
  28.            
  29.             <tr><td><label>Mailing Address (If different):</label></td><td colspan="3"><input type="text" name="mailing" id="mailing" style="width:320px;" /></td>
  30.             <td><label>Home Phone:</label></td><td><input type="text" name="hphone" id="hphone" /></td></tr>
  31.             <tr><td><label>Mobile Phone:</label></td><td><input type="text" name="mphone" id="mphone" /></td>
  32.             <td><label>Work Phone:</label></td><td><input type="text" name="wphone" id="wphone" /></td>
  33.             <td><label>Ext:</label></td><td><input type="text" name="ext" id="ext" /></td></tr>
  34.             <tr><td><label>Fax:</label></td><td><input type="text" name="fax" id="fax" /></td>
  35.             <td><label>E-mail:</label></td><td colspan="3"><input type="text" name="email" id="email" style="width:320px;" /></td></tr>
  36.            
  37.             <tr><td><label>Ethnic Group:</label></td><td><select id="ethgroup" name="ethgroup"><option>African American</option><option>American Indian/Alaska Native</option><option>Asian/Pacific Islander</option><option>Hispanic</option><option>White</option><option>Other</option></select></td>
  38.  
  39.             <td><label>Specify if other:</label></td><td colspan="3"><input type="text" name="other1" id="other1" style="width:320px;" /></td></tr>
  40.             <tr><td><label>Occupation:</label></td><td colspan="1" width="200px"><input type="text" name="occupation" id="occupation" style="width:200px;" /></td>
  41.             <td><label>Place of Employment:</label></td><td colspan="3"><input type="text" name="poe" id="poe" style="width:200px" /></td></tr>
  42.             <tr><td><label>Date of Birth:</label></td><td><input type="date" name="dob" id="dob" /></td>
  43.            
  44.                 <td><label>Gender:</label></td><td colspan="3"><select id="gender" name="gender"><option>Female</option><option>Male</option></select></td></tr>
  45.             <tr><td><label>Disaster Volunteer:</label></td><td><input type="checkbox" id="disastervoln" name="disastervoln[]" value="BHV">BHV</td>
  46.             <td><input type="checkbox" id="disastervoln" name="disastervoln[]" value="MRC">MRC</td>
  47.             <td><input type="checkbox" id="disastervoln" name="disastervoln[]" value="General">General</td>
  48.             <td colspan="2"><input type="checkbox" id="disastervoln" name="disastervoln[]" value="EVV">EVC </td>
  49.             </table>
  50.             <table style="border: 1px solid black; width:850px;">
  51.             <tr><td colspan="6"><center><label>Service Counties</label></center></td></tr>
  52.             <tr><td style="width:141.3px"><input type="checkbox" id="scounty" name="scounty[]" value="All">All</td>
  53.             <td style="width:141.3px"><input type="checkbox" class="scounty" name="scounty[]" value="Fillmore">Fillmore</td>
  54.             <td style="width:141.3px"><input type="checkbox" class="scounty" name="scounty[]" value="Jonhson">Johnson</td>
  55.             <td style="width:141.3px"><input type="checkbox" class="scounty" name="scounty[]" value="Otoe">Otoe</td>
  56.             <td style="width:141.3px"><input type="checkbox" class="scounty" name="scounty[]" value="Richardson">Richardson</td>
  57.             <td style="width:141.3px"><input type="checkbox" class="scounty" name="scounty[]" value="Seward">Seward</td></tr>
  58.             <tr><td><input type="checkbox" class="scounty" name="scounty[]" value="Butler">Butler</td>
  59.             <td><input type="checkbox" class="scounty" name="scounty[]" value="Gage">Gage</td>
  60.             <td><input type="checkbox" class="scounty" name="scounty[]" value="Lancaster">Lancaster</td>
  61.             <td><input type="checkbox" class="scounty" name="scounty[]" value="Pawnee">Pawnee</td>
  62.             <td><input type="checkbox" class="scounty" name="scounty[]" value="Saline">Saline</td>
  63.             <td><input type="checkbox" class="scounty" name="scounty[]" value="Thayer">Thayer</td></tr>
  64.             <tr><td><input type="checkbox" class="scounty" name="scounty[]" value="Cass">Cass</td>
  65.             <td><input type="checkbox" class="scounty" name="scounty[]" value="Jefferson">Jefferson</td>
  66.             <td><input type="checkbox" class="scounty" name="scounty[]" value="Nemaha">Nemaha</td>
  67.             <td><input type="checkbox" class="scounty" name="scounty[]" value="Polk">Polk</td>
  68.             <td><input type="checkbox" class="scounty" name="scounty[]" value="Saunders">Saunders</td>
  69.             <td><input type="checkbox" class="scounty" name="scounty[]" value="York">York</td>
  70.             <tr><td><label>Specify if other</label></td><td colspan="5"><input type="text" name="other2" id="other2" /></td></tr>
  71.             </table>
  72.             <table style="width:850px; border: 1px solid black;">
  73.             <tr><td colspan="6"><center><label>Volunteer Skills</label></center></td></tr>
  74.             <tr><td><input type="checkbox" id="vSkills" name="vSkills[]" value="Amateur Radio Operator">Amateur Radio Operator</td>
  75.             <td><input type="checkbox" id="vSkills" name="vSkills[]" value="Clergy">Clergy</td>
  76.             <td><input type="checkbox" id="vSkills" name="vSkills[]" value="Interpreter Skills">Interpreter Skills</td>
  77.                 <td><label>Languages?</label></td>
  78.                     <td colspan="2"><input type="text" name="interpt" id="interpt" /></td></tr>
  79.             <tr><td><input type="checkbox" id="vSkills" name="vSkills[]" value="Bus/Truck Driver">Bus/Truck Driver</td>
  80.                 <td><label>Is CDL Current?</label></td>
  81.                         <td><select name="cdl" id="cdl"><option>Yes</option><option>No</option></select></td>
  82.             <td><input type="checkbox" id="vSkills" name="vSkills[]" value="Child Care">Child Care</td>
  83.             <td colspan="2"><input type="checkbox" id="vSkills" name="vSkills[]" value="Law Enforcement">Law Enforcement</td></tr>
  84.             <tr><td><input type="checkbox" id="vSkills" name="vSkills[]" value="CPR">CPR</td>
  85.                 <td><label>Is CPR card Current?</label></td>
  86.                     <td><select name="cpryn" id="cpryn" ><option>Yes</option><option>No</option></select></td>
  87.             <td><input type="checkbox" id="vSkills" name="vSkills[]" value="Data Entry">Data Entry</td>
  88.             <td colspan="2"><input type="checkbox" id="vSkills" name="vSkills[]" value="security">Security</td></tr>
  89.             <tr><td><input type="checkbox" id="vSkills" name="vSkills[]" value="Emergency Communication">Emergency Communication</td>
  90.             <td style="width:125px;"><input type="checkbox" id="vSkills" name="vSkills[]" value="Computer Skills">Computer Skills  </td>
  91.             <td><input type="checkbox" id="vSkills" name="vSkills[]" value="Mechanical Ability">Mechanical Ability</td>
  92.             <td><input type="checkbox" id="vSkills" name="vSkills[]" value="Administratiion/Office Skills">Administration/Office Skills</td>
  93.             <td colspan="2"><input type="checkbox" id="vSkills" name="vSkills[]" value="Mechanical Ability">Mechanical Ability</td></tr>
  94.             <tr><td><input type="checkbox" id="vSkills" name="vSkills[]" value="First Aid">First Aid</td>
  95.                 <td><label>Is F. Aid Card Current?</label></td>
  96.                 <td><select name="faid" id="faid"><option>Yes</option><option>No</option></select></td>
  97.             <td><input type="checkbox" id="vSkills" name="vSkills[]" value="Translation Skills">Translation Skills</td>
  98.                <td><label>Languages?</label></td>
  99.                    <td><input type="text" name="translate" id="translate" /></td></tr>
  100.             <tr><td><input type="checkbox" id="vSkills" name="vSkills[]" value="Construction"> Construction</td>
  101.             <td><input type="checkbox" id="vSkills" name="vSkills[]" value="Mechanical Ability">Mechanical Ability</td>
  102.             <td><input type="checkbox" id="vSkills" name="vSkills[]" value="Administratiion/Office Skills">Administration/Office Skills</td>
  103.             <td><input type="checkbox" id="vSkills" name="vSkills[]" value="Food Preparation">Food Preparation</td>    
  104.             <td><input type="checkbox" id="vSkills" name="vSkills[]" value="Animal Care/Rescue">Animal Care/Rescue</td>
  105.             <td><input type="checkbox" id="vSkills" name="vSkills[]" value="Heavy Equipment Operation">Heavy Equipment Operation</td></tr>
  106.             <tr><td><input type="checkbox" id="vSkills" name="vSkills[]" value="Basic Clean-up Skills">Basic Clean-up Skills</td>
  107.                 <td><label>Specify if other</label></td>
  108.                     <td colspan="4"><input type="text" name="other3" id="other3" /></td></tr>
  109.             </table>
  110.             <table style="width: 850px; border: black 1px solid;">
  111.                 <tr><td colspan="2"><label>1-License/Certificate:</label></td><td colspan="4"><select name="license1" id="license1"><option>Advanced Practical Registered Nurse</option><option>Commercial Drivers License</option><option>Certified Master Social Worker</option><option>Certified Nursing Assistant</option><option>Certified Professional Counselor</option><option>Certified Registered Nurse Anesthetist</option><option>Certified Social Worker</option><option>Emergency Medical Technician</option><option>Emergency Medical Technician-Intermediate</option><option>Emergency Medical Technician-Paramedic</option><option>First Responder</option><option>Licensed Alcohol and Drug Counselor</option><option>Licensed Child Care Provider</option><option>Licensed Mental Health Practitioner</option><option>Licensed Practical Nurse</option><option>Lab Technician</option><option>Medication Aid</option><option>Medical Doctor</option><option>Marriage and Family Therapist</option><option>Nurse Aid</option><option>NotChoose</option><option>Nurse Practitioner</option><option>Physician</option><option>Physician Assistant</option><option>Provisionally Certified Master Social Worker</option><option>Pharmacist</option><option>Provisional Licensed Alcohol & Drug Counselor</option><option>Provisionally Licensed Mental Health Practitioner</option><option>Psychiatrist</option><option>Provisional Psychologist</option><option>Psychologist Assistant</option><option>Psychologist  </option><option>Registered Nurse</option><option>Veterinarian</option><option>Veterinarian Technician</option></select></td></tr>
  112.                <tr><td><label>Verification date</label></td><td><input type="date" name="verf1" id="verf1" /></td>
  113.                    <td><label>License/Certificate #:</label></td><td><input type="text" name="num1" id="num1" /></td>
  114.                    <td><label>Expiration date</label></td><td><input type="date" name="exp1" id="exp1" /></td></tr>
  115.                <tr><td colspan="2"><label>2-License/Certificate:</label></td><td colspan="4"><select name="license2" id="license2"><option>Advanced Practical Registered Nurse</option><option>Commercial Drivers License</option><option>Certified Master Social Worker</option><option>Certified Nursing Assistant</option><option>Certified Professional Counselor</option><option>Certified Registered Nurse Anesthetist</option><option>Certified Social Worker</option><option>Emergency Medical Technician</option><option>Emergency Medical Technician-Intermediate</option><option>Emergency Medical Technician-Paramedic</option><option>First Responder</option><option>Licensed Alcohol and Drug Counselor</option><option>Licensed Child Care Provider</option><option>Licensed Mental Health Practitioner</option><option>Licensed Practical Nurse</option><option>Lab Technician</option><option>Medication Aid</option><option>Medical Doctor</option><option>Marriage and Family Therapist</option><option>Nurse Aid</option><option>NotChoose</option><option>Nurse Practitioner</option><option>Physician</option><option>Physician Assistant</option><option>Provisionally Certified Master Social Worker</option><option>Pharmacist</option><option>Provisional Licensed Alcohol & Drug Counselor</option><option>Provisionally Licensed Mental Health Practitioner</option><option>Psychiatrist</option><option>Provisional Psychologist</option><option>Psychologist Assistant</option><option>Psychologist  </option><option>Registered Nurse</option><option>Veterinarian</option><option>Veterinarian Technician</option></select></td></tr>
  116.                <tr><td><label>Verification date</label></td><td><input type="date" name="verf2" id="verf2" /> </td>
  117.                    <td><label>License/Certificate #:</label></td><td><input type="text" name="num2" id="num2" /></td>
  118.                    <td><label>Expiration date</label></td><td><input type="date" name="exp2" id="exp2" /></td></tr>
  119.                <tr><td colspan="2"><label>3-License/Certificate:</label></td><td colspan="4"><select name="license3" id="license3"><option>Advanced Practical Registered Nurse</option><option>Commercial Drivers License</option><option>Certified Master Social Worker</option><option>Certified Nursing Assistant</option><option>Certified Professional Counselor</option><option>Certified Registered Nurse Anesthetist</option><option>Certified Social Worker</option><option>Emergency Medical Technician</option><option>Emergency Medical Technician-Intermediate</option><option>Emergency Medical Technician-Paramedic</option><option>First Responder</option><option>Licensed Alcohol and Drug Counselor</option><option>Licensed Child Care Provider</option><option>Licensed Mental Health Practitioner</option><option>Licensed Practical Nurse</option><option>Lab Technician</option><option>Medication Aid</option><option>Medical Doctor</option><option>Marriage and Family Therapist</option><option>Nurse Aid</option><option>NotChoose</option><option>Nurse Practitioner</option><option>Physician</option><option>Physician Assistant</option><option>Provisionally Certified Master Social Worker</option><option>Pharmacist</option><option>Provisional Licensed Alcohol & Drug Counselor</option><option>Provisionally Licensed Mental Health Practitioner</option><option>Psychiatrist</option><option>Provisional Psychologist</option><option>Psychologist Assistant</option><option>Psychologist  </option><option>Registered Nurse</option><option>Veterinarian</option><option>Veterinarian Technician</option></select></td></tr>
  120.                <tr><td><label>Verification date</label></td><td><input type="date" name="verf3" id="verf3" /></td>
  121.                    <td><label>License/Certificate #:</label></td><td><input type="text" name="num3" id="num3" /></td>
  122.                    <td><label>Expiration date</label></td><td><input type="date" name="exp3" id="exp3" /></td></tr>
  123.                <tr><td colspan="2"><label>4-License/Certificate:</label></td><td colspan="4"><select name="license4" id="license4"><option>Advanced Practical Registered Nurse</option><option>Commercial Drivers License</option><option>Certified Master Social Worker</option><option>Certified Nursing Assistant</option><option>Certified Professional Counselor</option><option>Certified Registered Nurse Anesthetist</option><option>Certified Social Worker</option><option>Emergency Medical Technician</option><option>Emergency Medical Technician-Intermediate</option><option>Emergency Medical Technician-Paramedic</option><option>First Responder</option><option>Licensed Alcohol and Drug Counselor</option><option>Licensed Child Care Provider</option><option>Licensed Mental Health Practitioner</option><option>Licensed Practical Nurse</option><option>Lab Technician</option><option>Medication Aid</option><option>Medical Doctor</option><option>Marriage and Family Therapist</option><option>Nurse Aid</option><option>NotChoose</option><option>Nurse Practitioner</option><option>Physician</option><option>Physician Assistant</option><option>Provisionally Certified Master Social Worker</option><option>Pharmacist</option><option>Provisional Licensed Alcohol & Drug Counselor</option><option>Provisionally Licensed Mental Health Practitioner</option><option>Psychiatrist</option><option>Provisional Psychologist</option><option>Psychologist Assistant</option><option>Psychologist  </option><option>Registered Nurse</option><option>Veterinarian</option><option>Veterinarian Technician</option></select></td></tr>
  124.                <tr><td><label>Verification date</label></td><td><input type="date" name="verf4" id="verf4" /></td>
  125.                    <td><label>License/Certificate #:</label></td><td><input type="text" name="num4" id="num4" /></td>
  126.                    <td><label>Expiration date</label></td><td><input type="date" name="exp4" id="exp4" /></td></tr>
  127.                <tr><td colspan="2"><label>5-License/Certificate:</label></td><td colspan="4"><select name="license5" id="license5"><option>Advanced Practical Registered Nurse</option><option>Commercial Drivers License</option><option>Certified Master Social Worker</option><option>Certified Nursing Assistant</option><option>Certified Professional Counselor</option><option>Certified Registered Nurse Anesthetist</option><option>Certified Social Worker</option><option>Emergency Medical Technician</option><option>Emergency Medical Technician-Intermediate</option><option>Emergency Medical Technician-Paramedic</option><option>First Responder</option><option>Licensed Alcohol and Drug Counselor</option><option>Licensed Child Care Provider</option><option>Licensed Mental Health Practitioner</option><option>Licensed Practical Nurse</option><option>Lab Technician</option><option>Medication Aid</option><option>Medical Doctor</option><option>Marriage and Family Therapist</option><option>Nurse Aid</option><option>NotChoose</option><option>Nurse Practitioner</option><option>Physician</option><option>Physician Assistant</option><option>Provisionally Certified Master Social Worker</option><option>Pharmacist</option><option>Provisional Licensed Alcohol & Drug Counselor</option><option>Provisionally Licensed Mental Health Practitioner</option><option>Psychiatrist</option><option>Provisional Psychologist</option><option>Psychologist Assistant</option><option>Psychologist  </option><option>Registered Nurse</option><option>Veterinarian</option><option>Veterinarian Technician</option></select></td></tr>
  128.                <tr><td><label>Verification date</label></td><td><input type="date" name="verf5" id="verf5" /></td>
  129.                    <td><label>License/Certificate #:</label></td><td><input type="text" name="num5" id="num5" /></td>
  130.                    <td><label>Expiration date</label></td><td><input type="date" name="exp5" id="exp5" /></td></tr>
  131.            </table>
  132.            <table style="width:850px; border:1px solid black;">
  133.                 <tr><td><label>License Suspended/Revoked/Disciplined(Yes/No):</label></td><td><select name="lsrd" id="lsrd"><option>yes</option><option>no</option></select></td>
  134.                     <td><label>Specify if "Yes"</label></td><td><input type="text" name="syes" id="syes" /></td></tr>
  135.                 <tr><td><label>Board Certified(Yes/No):</label></td><td><select name="bcert" id="bcert"><option>yes</option><option>no</option></select></td>
  136.                     <td><label>Prescriptive Authority(Yes/No):</label></td><td><select name="pauth" id="pauth"><option>yes</option><option>no</option></select></td></tr>
  137.             </table>
  138.             <table style="width:850px; border:1px solid black;">
  139.                 <tr><td colspan="4"><center><label>EVC Roles</label></center></td></tr>
  140.                
  141.                 <tr><td><input type="checkbox" id="etrain" name="etrain[]" value="Data Entry">Data Entry</td>
  142.                     <td><input type="checkbox" id="etrain" name="etrain[]" value="Identification Staff">Identification staff</td>
  143.                     <td><input type="checkbox" id="etrain" name="etrain[]" value="Phone Bank Staff">Phone Bank Staff</td>
  144.                     <td><input type="checkbox" id="etrain" name="etrain[]" value="Runner">Runner</td></tr>
  145.                     <tr><td><input type="checkbox" id="etrain" name="etrain[]" value="Greeter">Greeter</td>
  146.                     <td><input type="checkbox" id="etrain" name="etrain[]" value="Interviewer">Interviewer</td>
  147.                     <td colspan="2"><input type="checkbox" id="etrain" name="etrain[]" value="Safety Orientation">Safety Orientation</td></tr>
  148.             </table>        
  149.             <table style="width:850px; border: 1px solid black;">
  150.                 <tr><td><label>1- Disaster Training</label></td><td colspan="2"><select name="dist1"><option>Advanced Disaster Life Support</option><option>American Red Cross Disaster Mental Health</option><option>Basic Disaster Life Support</option><option>Community Emergency Response Team (CERT)</option><option>Critical Incident Stress Management Advanced (CISM)</option><option>Critical Incident Stress Management Basic</option><option>Emergency  Volunteer Center (EVC)</option><option>FEMA Crisis Counseling Grant</option><option>NotChoose</option><option>Nebraska Psychological First Aid</option><option>National Incident Management System (NIMS)</option><option>Other</option></select></td>
  151.                     <td><label>Training Date</label></td><td><input type="date" name="tdate1" /></td></tr>
  152.                 <tr><td><label>2- Disaster Training</label></td><td colspan="2"><select name="dist2"><option>Advanced Disaster Life Support</option><option>American Red Cross Disaster Mental Health</option><option>Basic Disaster Life Support</option><option>Community Emergency Response Team (CERT)</option><option>Critical Incident Stress Management Advanced (CISM)</option><option>Critical Incident Stress Management Basic</option><option>Emergency  Volunteer Center (EVC)</option><option>FEMA Crisis Counseling Grant</option><option>NotChoose</option><option>Nebraska Psychological First Aid</option><option>National Incident Management System (NIMS)</option><option>Other</option></select></td>
  153.                     <td><label>Training Date</label></td><td><input type="date" name="tdate2" /></td></tr>
  154.                 <tr><td><label>3- Disaster Training</label></td><td colspan="2"><select name="dist3"><option>Advanced Disaster Life Support</option><option>American Red Cross Disaster Mental Health</option><option>Basic Disaster Life Support</option><option>Community Emergency Response Team (CERT)</option><option>Critical Incident Stress Management Advanced (CISM)</option><option>Critical Incident Stress Management Basic</option><option>Emergency  Volunteer Center (EVC)</option><option>FEMA Crisis Counseling Grant</option><option>NotChoose</option><option>Nebraska Psychological First Aid</option><option>National Incident Management System (NIMS)</option><option>Other</option></select></td>
  155.                     <td><label>Training Date</label></td><td><input type="date" name="tdate3" /></td></tr>
  156.                 <tr><td><label>4- Disaster Training</label></td><td colspan="2"><select name="dist4"><option>Advanced Disaster Life Support</option><option>American Red Cross Disaster Mental Health</option><option>Basic Disaster Life Support</option><option>Community Emergency Response Team (CERT)</option><option>Critical Incident Stress Management Advanced (CISM)</option><option>Critical Incident Stress Management Basic</option><option>Emergency  Volunteer Center (EVC)</option><option>FEMA Crisis Counseling Grant</option><option>NotChoose</option><option>Nebraska Psychological First Aid</option><option>National Incident Management System (NIMS)</option><option>Other</option></select></td>
  157.                     <td><label>Training Date</label></td><td><input type="date" name="tdate4" /></td></tr>
  158.                 <tr><td><label>5- Disaster Training</label></td><td colspan="2"><select name="dist5"><option>Advanced Disaster Life Support</option><option>American Red Cross Disaster Mental Health</option><option>Basic Disaster Life Support</option><option>Community Emergency Response Team (CERT)</option><option>Critical Incident Stress Management Advanced (CISM)</option><option>Critical Incident Stress Management Basic</option><option>Emergency  Volunteer Center (EVC)</option><option>FEMA Crisis Counseling Grant</option><option>NotChoose</option><option>Nebraska Psychological First Aid</option><option>National Incident Management System (NIMS)</option><option>Other</option></select></td>
  159.                     <td><label>Training Date</label></td><td><input type="date" name="tdate5" /></td></tr>
  160.             </table>
  161.             <table style="width:850px; border:solid black 1px;">
  162.                 <tr><td><label>Convicted of a Felony (Not traffic violations) (Yes/No)</label></td><td><select name="felony>"><option>Yes</option><option>No</option></select></td>
  163.                     <td><label>Specify if Yes</label></td><td><input type="text" name="felonys" /></td></tr>
  164.             </table>
  165.             <table style="width:850px; border:solid black 1px;">
  166.                 <tr><td><label>Home:</label></td><td colspan="2"><input type="text" name="ehome" /></td>
  167.                     <td><label>Relationship:</label></td><td colspan="2"><input type="text" name="erelation" style="width:300px;" /> </td></tr>
  168.                 <tr><td><label>Home phone:</label></td><td><input type="text" name="ehphone" /></td>
  169.                     <td><label>Mobile phone:</label></td><td><input type="text" name="emphone" /></td>
  170.                     <td><label>Address:</label></td><td><input type="text" name="eaddress" /></td></tr>
  171.                 <tr><td><label>City:</label></td><td><input type="text" name="ecity" /></td>
  172.                     <td><label>State:</label></td><td><input type="text" name="estate" /></td>
  173.                     <td><label>Zip:</label></td><td><input type="text" name="ezip" /></td></tr>
  174.             </table>
  175.             <table style="width:850px; border:solid black 1px;">
  176.                 <tr><td><label>How Did you hear about us?</label></td><td><select name="hdyhau"><option>Friend</option><option>County Fair</option><option>Health fair</option><option>Local Service Club</option><option>Newspaper</option><option>Website</option><option>Other Community Event</option></select></td></tr>
  177.                 <tr><td><label>Brief description and other info</label></td><td><input type="text" name="bdesc" style="width:300px;" /> </td></tr>
  178.             </table>
  179.             <input type="submit" value="Submit" />
  180.        </form>
  181. </center>
  182.             <br><br><br>
  183.     </body>
  184. </html>
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