API tools faq
paste
Advertisement
Guest User

volunForm.php

a guest
Sep 4th, 2014
440
0
Never
Add comment
Not a member of Pastebin yet? Sign Up, it unlocks many cool features!
PHP 28.79 KB | None | 0 0
raw download clone embed print report
  1. <?php
  2. session_start();
  3. if(!isset($_SESSION['sess_user_id']) || (trim($_SESSION['sess_user_id']) == '')) {
  4.     header("location: login.php");
  5.     exit();
  6. }
  7. ?>
  8. <!DOCTYPE html>
  9. <html>
  10.     <head>
  11.         <meta charset="UTF-8">
  12.         <title>Volunteer Database</title>
  13.         <script type="text/javascript" src="js/functions.js"> </script>
  14.         <link rel="stylesheet" href="css/bootstrap-theme.css" type="text/css" />
  15.         <link rel="stylesheet" href="css/bootstrap.css" type="text/css" />
  16.         <link rel="stylesheet" href="css/styles.css" type="text/css">
  17.         <script src="http://code.jquery.com/jquery-latest.min.js" type="text/javascript"></script>
  18.     </head>
  19.     <body>
  20.         <div class="sidebar">
  21.             <ul class="nav nav-pills nav-stacked">
  22.                 <li>Welcome  <?php echo $_SESSION["sess_name"] ?></li>
  23.                 <li><a href="logout.php">Logout</a></li>
  24.                 <li><a href="home.php">Home</a><li>
  25.                 <li class="active"><a href="volunForm.php">Add Volunteer</a></li>
  26.                 <li><a href="search.php">Search/Report</a></li>
  27.                 <li><a href="allVolun.php">View Volunteers</a></li>
  28.                 <li><a href="updateVolunteer.php">Update Volunteer</a></li>
  29.                
  30.             </ul>
  31.         </div>
  32.         <div class="content">
  33.         <br><br><br>
  34.         <form action="add.php" method="post">
  35.         <center><table style="border:1px solid black; width:850px; padding:2px;">
  36.            <tr>
  37.                <td><label>First Name:</label></td><td><input type="text" name="fname" id="fname" /></td>
  38.            <td><label>Middle Initial:</label></td><td><input type="text" name="middle" id="middle" /></td>
  39.            <td><label>Last Name:</label></td><td><input type="text" name="lname" id="lname" /></td></tr>
  40.             <tr><td><label>Street Address:</label></td><td colspan="3"><input type="text" name="address" id="address" style="width:320px;" /></td>
  41.             <td><label>City:</label></td><td><input type="text" name="city" id="city" /></td></tr>
  42.             <tr><td><label>State:</label></td><td><input type="text" name="state" id="state" /></td>
  43.                 <td><label>ZIP:</label></td><td><input type="text" name="zip" id="zip" /></td>
  44.                 <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>
  45.            
  46.             <tr><td><label>Mailing Address (If different):</label></td><td colspan="3"><input type="text" name="mailing" id="mailing" style="width:320px;" /></td>
  47.             <td><label>Home Phone:</label></td><td><input type="text" name="hphone" id="hphone" /></td></tr>
  48.             <tr><td><label>Mobile Phone:</label></td><td><input type="text" name="mphone" id="mphone" /></td>
  49.             <td><label>Work Phone:</label></td><td><input type="text" name="wphone" id="wphone" /></td>
  50.             <td><label>Ext:</label></td><td><input type="text" name="ext" id="ext" /></td></tr>
  51.             <tr><td><label>Fax:</label></td><td><input type="text" name="fax" id="fax" /></td>
  52.             <td><label>E-mail:</label></td><td colspan="3"><input type="text" name="email" id="email" style="width:320px;" /></td></tr>
  53.            
  54.             <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>
  55.  
  56.             <td><label>Specify if other:</label></td><td colspan="3"><input type="text" name="other1" id="other1" style="width:320px;" /></td></tr>
  57.             <tr><td><label>Occupation:</label></td><td colspan="1" width="200px"><input type="text" name="occupation" id="occupation" style="width:200px;" /></td>
  58.             <td><label>Place of Employment:</label></td><td colspan="3"><input type="text" name="poe" id="poe" style="width:200px" /></td></tr>
  59.             <tr><td><label>Date of Birth:</label></td><td><input type="date" name="dob" id="dob" /></td>
  60.            
  61.                 <td><label>Gender:</label></td><td colspan="3"><select id="gender" name="gender"><option>Female</option><option>Male</option></select></td></tr>
  62.             <tr><td><label>Disaster Volunteer:</label></td><td><input type="checkbox" id="disastervoln" name="bhv" value="BHV"><b>BHV</b></td>
  63.                 <td><input type="checkbox" id="disastervoln" name="mrc" value="MRC"><b>MRC</b></td>
  64.                 <td><input type="checkbox" id="disastervoln" name="general" value="General"><b>General</b></td>
  65.                 <td colspan="2"><input type="checkbox" id="disastervoln" name="evv" value="EVV"><b>EVC</b> </td>
  66.             </table>
  67.             <table style="border: 1px solid black; width:850px;">
  68.             <tr><td colspan="6"><center><label>Service Counties</label></center></td></tr>
  69.             <tr><td style="width:141.3px"><input type="checkbox" id="scounty" name="allCounties" value="All"><b>All</b></td>
  70.                 <td style="width:141.3px"><input type="checkbox" class="scounty" name="fillmore" value="Fillmore"><b>Fillmore</b></td>
  71.                 <td style="width:141.3px"><input type="checkbox" class="scounty" name="johnson" value="Jonhson"><b>Johnson</b></td>
  72.                 <td style="width:141.3px"><input type="checkbox" class="scounty" name="otoe" value="Otoe"><b>Otoe</b></td>
  73.                 <td style="width:141.3px"><input type="checkbox" class="scounty" name="richardson" value="Richardson"><b>Richardson</b></td>
  74.                 <td style="width:141.3px"><input type="checkbox" class="scounty" name="seward" value="Seward"><b>Seward</b></td></tr>
  75.             <tr><td><input type="checkbox" class="scounty" name="butler" value="Butler"><b>Butler</b></td>
  76.                 <td><input type="checkbox" class="scounty" name="gage" value="Gage"><b>Gage</b></td>
  77.                 <td><input type="checkbox" class="scounty" name="lancaster" value="Lancaster"><b>Lancaster</b></td>
  78.                 <td><input type="checkbox" class="scounty" name="pawnee" value="Pawnee"><b>Pawnee</b></td>
  79.                 <td><input type="checkbox" class="scounty" name="saline" value="Saline"><b>Saline</b></td>
  80.                 <td><input type="checkbox" class="scounty" name="thayer" value="Thayer"><b>Thayer</b></td></tr>
  81.             <tr><td><input type="checkbox" class="scounty" name="cass" value="Cass"><b>Cass</b></td>
  82.                 <td><input type="checkbox" class="scounty" name="jefferson" value="Jefferson"><b>Jefferson</b></td>
  83.                 <td><input type="checkbox" class="scounty" name="nemaha" value="Nemaha"><b>Nemaha</b></td>
  84.                 <td><input type="checkbox" class="scounty" name="polk" value="Polk"><b>Polk</b></td>
  85.                 <td><input type="checkbox" class="scounty" name="saunders" value="Saunders"><b>Saunders</b></td>
  86.                 <td><input type="checkbox" class="scounty" name="york" value="York"><b>York</b></td>
  87.             <tr><td><label>Specify if other</label></td><td colspan="5"><input type="text" name="other2" id="other2" /></td></tr>
  88.             </table>
  89.             <table style="width:850px; border: 1px solid black;">
  90.             <tr><td colspan="6"><center><label>Volunteer Skills</label></center></td></tr>
  91.             <tr><td><input type="checkbox" id="vSkills" name="aro" value="Amateur Radio Operator"><b>Amateur Radio Operator</b></td>
  92.             <td><input type="checkbox" id="vSkills" name="clergy" value="Clergy"><b>Clergy</b></td>
  93.             <td colspan="2"><input type="checkbox" id="vSkills" name="intskills" value="Interpreter Skills"><b>Interpreter Skills</b></td>
  94.                 <td><label>Languages?</label></td>
  95.                     <td colspan="2"><input type="text" name="interpt" id="interpt" /></td></tr>
  96.             <tr><td><input type="checkbox" id="vSkills" name="bus" value="Bus/Truck Driver"><b>Bus/Truck Driver</b></td>
  97.                 <td><label>Is CDL Current?</label></td>
  98.                         <td><select name="cdl" id="cdl"><option></option><option>Yes</option><option>No</option></select></td>
  99.             <td><input type="checkbox" id="vSkills" name="child" value="Child Care"><b>Child Care</b></td>
  100.             <td colspan="2"><input type="checkbox" id="vSkills" name="law" value="Law Enforcement"><b>Law Enforcement</b></td></tr>
  101.             <tr><td><input type="checkbox" id="vSkills" name="cpr" value="CPR"><b>CPR</b></td>
  102.                 <td><label>Is CPR card Current?</label></td>
  103.                     <td><select name="cpryn" id="cpryn" ><option></option><option>Yes</option><option>No</option></select></td>
  104.             <td><input type="checkbox" id="vSkills" name="data" value="Data Entry"><b>Data Entry</b></td>
  105.             <td colspan="2"><input type="checkbox" id="vSkills" name="security" value="security"><b>Security</b></td></tr>
  106.             <tr><td><input type="checkbox" id="vSkills" name="emergency" value="Emergency Communication"><b>Emergency Communication</b></td>
  107.             <td style="width:125px;"><input type="checkbox" id="vSkills" name="computer" value="Computer Skills"><b>Computer Skills</b>  </td>
  108.             <td><input type="checkbox" id="vSkills" name="mechanical" value="Mechanical Ability"><b>Mechanical Ability</b></td>
  109.             <td colspan="2"><input type="checkbox" id="vSkills" name="administration" value="Administratiion/Office Skills"><b>Administration/Office Skills</b></td></tr>
  110.             <tr><td><input type="checkbox" id="vSkills" name="firstaid" value="First Aid"><b>First Aid</b></td>
  111.                 <td><label>Is F. Aid Card Current?</label></td>
  112.                 <td><select name="faid" id="faid"><option></option><option>Yes</option><option>No</option></select></td>
  113.             <td><input type="checkbox" id="vSkills" name="translation" value="Translation Skills"><b>Translation Skills</b></td>
  114.                <td><label>Languages?</label></td>
  115.                    <td><input type="text" name="translate" id="translate" /></td></tr>
  116.             <tr><td><input type="checkbox" id="vSkills" name="construction" value="Construction"> <b>Construction</b></td>
  117.             <td><input type="checkbox" id="vSkills" name="basicclean" value="Basic Clean-up Skills"><b>Basic Clean-up Skills</b></td>
  118.             <td><input type="checkbox" id="vSkills" name="foodprep" value="Food Preparation"><b>Food Preparation</b></td>    
  119.             <td><input type="checkbox" id="vSkills" name="animalcare" value="Animal Care/Rescue"><b>Animal Care/Rescue</b></td>
  120.             <td colspan="2"><input type="checkbox" id="vSkills" name="heavy" value="Heavy Equipment Operation"><b>Heavy Equipment Operation</b></td></tr>
  121.             <tr>
  122.                 <td><label>Specify if other</label></td>
  123.                     <td colspan="5"><input type="text" name="other3" id="other3" /></td></tr>
  124.             </table>
  125.             <table style="width: 850px; border: black 1px solid;">
  126.                 <tr><td colspan="2"><label>1-License/Certificate:</label></td><td colspan="4"><select name="license1" id="license1"><option></option><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>
  127.                 <tr><td><label>Verification date</label></td><td><input type="date" name="verf1" id="verf1" /></td>
  128.                     <td><label>License/Certificate #:</label></td><td><input type="text" name="num1" id="num1" /></td>
  129.                     <td><label>Expiration date</label></td><td><input type="date" name="exp1" id="exp1" /></td></tr>
  130.                 <tr><td colspan="2"><label>2-License/Certificate:</label></td><td colspan="4"><select name="license2" id="license2"><option></option><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>
  131.                 <tr><td><label>Verification date</label></td><td><input type="date" name="verf2" id="verf2" /> </td>
  132.                     <td><label>License/Certificate #:</label></td><td><input type="text" name="num2" id="num2" /></td>
  133.                     <td><label>Expiration date</label></td><td><input type="date" name="exp2" id="exp2" /></td></tr>
  134.                 <tr><td colspan="2"><label>3-License/Certificate:</label></td><td colspan="4"><select name="license3" id="license3"><option></option><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>
  135.                 <tr><td><label>Verification date</label></td><td><input type="date" name="verf3" id="verf3" /></td>
  136.                     <td><label>License/Certificate #:</label></td><td><input type="text" name="num3" id="num3" /></td>
  137.                     <td><label>Expiration date</label></td><td><input type="date" name="exp3" id="exp3" /></td></tr>
  138.                 <tr><td colspan="2"><label>4-License/Certificate:</label></td><td colspan="4"><select name="license4" id="license4"><option></option><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>
  139.                 <tr><td><label>Verification date</label></td><td><input type="date" name="verf4" id="verf4" /></td>
  140.                     <td><label>License/Certificate #:</label></td><td><input type="text" name="num4" id="num4" /></td>
  141.                     <td><label>Expiration date</label></td><td><input type="date" name="exp4" id="exp4" /></td></tr>
  142.                 <tr><td colspan="2"><label>5-License/Certificate:</label></td><td colspan="4"><select name="license5" id="license5"><option></option><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>
  143.                 <tr><td><label>Verification date</label></td><td><input type="date" name="verf5" id="verf5" /></td>
  144.                     <td><label>License/Certificate #:</label></td><td><input type="text" name="num5" id="num5" /></td>
  145.                     <td><label>Expiration date</label></td><td><input type="date" name="exp5" id="exp5" /></td></tr>
  146.             </table>
  147.             <table style="width:850px; border:1px solid black;">
  148.                 <tr><td><label>License Suspended/Revoked/Disciplined(Yes/No):</label></td><td><select name="lsrd" id="lsrd"><option></option><option>yes</option><option>no</option></select></td>
  149.                     <td><label>Specify if "Yes"</label></td><td><input type="text" name="syes" id="syes" /></td></tr>
  150.                 <tr><td><label>Board Certified(Yes/No):</label></td><td><select name="bcert" id="bcert"><option></option><option>yes</option><option>no</option></select></td>
  151.                     <td><label>Prescriptive Authority(Yes/No):</label></td><td><select name="pauth" id="pauth"><option></option><option>yes</option><option>no</option></select></td></tr>
  152.             </table>
  153.             <table style="width:850px; border:1px solid black;">
  154.                 <tr><td colspan="4"><center><label>EVC Roles</label></center></td></tr>
  155.                
  156.                 <tr><td><input type="checkbox" id="etrain" name="dataentry" value="Data Entry"><b>Data Entry</b></td>
  157.                     <td><input type="checkbox" id="etrain" name="identification" value="Identification Staff"><b>Identification staff</b></td>
  158.                     <td><input type="checkbox" id="etrain" name="phone" value="Phone Bank Staff"><b>Phone Bank Staff</b></td>
  159.                     <td><input type="checkbox" id="etrain" name="runner" value="Runner"><b>Runner</b></td></tr>
  160.                     <tr><td><input type="checkbox" id="etrain" name="greeter" value="Greeter"><b>Greeter</b></td>
  161.                     <td><input type="checkbox" id="etrain" name="interviewer" value="Interviewer"><b>Interviewer</b></td>
  162.                     <td colspan="2"><input type="checkbox" id="etrain" name="safety" value="Safety Orientation"><b>Safety Orientation</b></td></tr>
  163.             </table>        
  164.             <table style="width:850px; border: 1px solid black;">
  165.                 <tr><td><label>1- Disaster Training</label></td><td colspan="2"><select name="dist1"><option></option><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>
  166.                     <td><label>Training Date</label></td><td><input type="date" name="tdate1" /></td></tr>
  167.                 <tr><td><label>2- Disaster Training</label></td><td colspan="2"><select name="dist2"><option></option><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>
  168.                     <td><label>Training Date</label></td><td><input type="date" name="tdate2" /></td></tr>
  169.                 <tr><td><label>3- Disaster Training</label></td><td colspan="2"><select name="dist3"><option></option><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>
  170.                     <td><label>Training Date</label></td><td><input type="date" name="tdate3" /></td></tr>
  171.                 <tr><td><label>4- Disaster Training</label></td><td colspan="2"><select name="dist4"><option></option><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>
  172.                     <td><label>Training Date</label></td><td><input type="date" name="tdate4" /></td></tr>
  173.                 <tr><td><label>5- Disaster Training</label></td><td colspan="2"><select name="dist5"><option></option><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>
  174.                     <td><label>Training Date</label></td><td><input type="date" name="tdate5" /></td></tr>
  175.             </table>
  176.             <table style="width:850px; border:solid black 1px;">
  177.                 <tr><td><label>Convicted of a Felony (Not traffic violations) (Yes/No)</label></td><td><select name="felony"><option></option><option>Yes</option><option>No</option></select></td>
  178.                     <td><label>Specify if Yes</label></td><td><input type="text" name="felonys" /></td></tr>
  179.             </table>
  180.             <table style="width:850px; border:solid black 1px;">
  181.                 <tr><td><label>Name:</label></td><td colspan="2"><input type="text" name="ename" /></td>
  182.                     <td><label>Relationship:</label></td><td colspan="2"><input type="text" name="erelation" style="width:300px;" /> </td></tr>
  183.                 <tr><td><label>Home phone:</label></td><td><input type="text" name="ehphone" /></td>
  184.                     <td><label>Mobile phone:</label></td><td><input type="text" name="emphone" /></td>
  185.                     <td><label>Address:</label></td><td><input type="text" name="eaddress" /></td></tr>
  186.                 <tr><td><label>City:</label></td><td><input type="text" name="ecity" /></td>
  187.                     <td><label>State:</label></td><td><input type="text" name="estate" /></td>
  188.                     <td><label>Zip:</label></td><td><input type="text" name="ezip" /></td></tr>
  189.             </table>
  190.             <table style="width:850px; border:solid black 1px;">
  191.                 <tr><td><label>How Did you hear about us?</label></td><td><select name="hdyhau"><option></option><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>
  192.                 <tr><td><label>Brief description and other info</label></td><td><input type="text" name="bdesc" style="width:300px;" /> </td></tr>
  193.             </table>
  194.             <input type="submit" class="btn btn-primary" value="Submit" />
  195.        </form>
  196. </center>
  197.             <br><br><br>
  198.             </div>
  199.     </body>
  200. </html>
Advertisement
Add Comment
Please, Sign In to add comment
Advertisement
Public Pastes
Advertisement
We use cookies for various purposes including analytics. By continuing to use Pastebin, you agree to our use of cookies as described in the Cookies Policy.  OK, I Understand
Not a member of Pastebin yet?
Sign Up, it unlocks many cool features!