API tools faq
paste
Advertisement
vincecudz

YDFA Pre-trip Questionnaire

vincecudz
Oct 24th, 2013
89
0
Never
Add comment
Not a member of Pastebin yet? Sign Up, it unlocks many cool features!
HTML 32.80 KB | None | 0 0
raw download clone embed print report
  1. <!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
  2. <html xmlns="http://www.w3.org/1999/xhtml">
  3. <head>
  4. <meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
  5. <meta name="viewport" content="width=device-width, initial-scale=1.0, maximum-scale=1.0, user-scalable=0" />
  6. <meta name="HandheldFriendly" content="true" />
  7. <title>YDFA Pre-trip Questionnaire</title>
  8. <link href="http://cdn.jotfor.ms/static/formCss.css?3.1.261" rel="stylesheet" type="text/css" />
  9. <link type="text/css" rel="stylesheet" href="http://cdn.jotfor.ms/css/styles/pastel.css?3.1.261" />
  10. <link type="text/css" media="print" rel="stylesheet" href="http://cdn.jotfor.ms/css/printForm.css?3.1.261" />
  11. <style type="text/css">
  12.     .form-label{
  13.         width:40px !important;
  14.     }
  15.     .form-label-left{
  16.         width:40px !important;
  17.     }
  18.     .form-line{
  19.         padding-top:6px;
  20.         padding-bottom:6px;
  21.     }
  22.     .form-label-right{
  23.         width:40px !important;
  24.     }
  25.     body, html{
  26.         margin:0;
  27.         padding:0;
  28.         background:#EBEBEB;
  29.     }
  30.  
  31.     .form-all{
  32.         margin:0px auto;
  33.         padding-top:20px;
  34.         width:720px;
  35.         background:#EBEBEB;
  36.         color:rgb(82, 75, 58) !important;
  37.         font-family:'Arial Black';
  38.         font-size:13px;
  39.     }
  40.     .form-radio-item label, .form-checkbox-item label, .form-grading-label, .form-header{
  41.         color:rgb(82, 75, 58);
  42.     }
  43.  
  44.     /* Injected CSS Code */
  45. .form-header-group {
  46. background: none repeat scroll 0 0 orange;}
  47. .form-line-active {
  48. background-color: orange;
  49. }
  50. .form-line-error {
  51. background: none repeat scroll 0 0;
  52. }
  53.  
  54. body {
  55. background-color: #AA9F55;
  56. background-image: url(http://www.yellowdogflyfishing.com/ydfa_questionnaires/background_pre_trip.jpg);
  57. background-repeat: no-repeat;
  58. background-attachment: fixed;
  59. }
  60.     /* Injected CSS Code */
  61. </style>
  62.  
  63. <link type="text/css" rel="stylesheet" href="http://jotform.us/css/styles/buttons/form-submit-button-black_blue.css?3.1.261"/>
  64. <script src="http://cdn.jotfor.ms/static/jotform.js?3.1.261" type="text/javascript"></script>
  65. <script type="text/javascript">
  66.    JotForm.init(function(){
  67.       JotForm.setCalendar("25", false);
  68.       JotForm.displayLocalTime("hour_25", "min_25", "ampm_25");
  69.       JotForm.setCalendar("86", false);
  70.       JotForm.displayLocalTime("hour_86", "min_86", "ampm_86");
  71.       $('input_14').hint('ex: myname@example.com');
  72.       JotForm.setCalendar("62", false);
  73.       JotForm.displayLocalTime("hour_62", "min_62", "ampm_62");
  74.       JotForm.setCalendar("71", false);
  75.       JotForm.displayLocalTime("hour_71", "min_71", "ampm_71");
  76.       JotForm.setCalendar("72", false);
  77.       JotForm.displayLocalTime("hour_72", "min_72", "ampm_72");
  78.       JotForm.setCalendar("85", false);
  79.       JotForm.displayLocalTime("hour_85", "min_85", "ampm_85");
  80.       JotForm.initCaptcha('input_16');
  81.    });
  82. </script>
  83. </head>
  84. <body>
  85. <form class="jotform-form" action="http://submit.jotform.us/submit/31644453340145/" method="post" name="form_31644453340145" id="31644453340145" accept-charset="utf-8">
  86.   <input type="hidden" name="formID" value="31644453340145" />
  87.   <div class="form-all">
  88.     <ul class="form-section">
  89. <div align="center" style="padding:10px; background-color:#F3D596; margin-top: -20px;">
  90.         <img src="http://www.yellowdogflyfishing.com/fly-fishing-vacation-site-images/ydformlogo.png" width="120" height="120">
  91. <h2 style="text-align:center; color:black;">
  92.             Yellow Dog Flyfishing Adventures<br>
  93.           Pre-Trip Questionnaire and Information Sheet </h2>
  94.         </div>
  95.    
  96.    
  97.     <li class="form-line form-line-column" id="id_6">
  98.         <label class="form-label-top" id="label_6" for="input_6">
  99.           Your Name<span class="form-required">*</span>
  100.         </label>
  101.         <div id="cid_6" class="form-input-wide">
  102.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_6" name="q6_yourName" size="50" value="" />
  103.         </div>
  104.       </li>
  105.       <li class="form-line form-line-column" id="id_65">
  106.         <label class="form-label-top" id="label_65" for="input_65">
  107.           Nickname<span class="form-required">*</span>
  108.         </label>
  109.         <div id="cid_65" class="form-input-wide">
  110.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_65" name="q65_nickname" size="38" value="" />
  111.         </div>
  112.       </li>
  113.       <li class="form-line form-line-column" id="id_23">
  114.         <label class="form-label-top" id="label_23" for="input_23">
  115.           Lodge/Destination<span class="form-required">*</span>
  116.         </label>
  117.         <div id="cid_23" class="form-input-wide">
  118.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_23" name="q23_lodgedestination" size="81" value="" />
  119.         </div>
  120.       </li>
  121.       <li class="form-line form-line-column" id="id_25">
  122.         <label class="form-label-top" id="label_25" for="input_25">
  123.           Start Date of Trip<span class="form-required">*</span>
  124.         </label>
  125.         <div id="cid_25" class="form-input-wide"><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="month_25" name="q25_startDate25[month]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  126.             <label class="form-sub-label" for="month_25" id="sublabel_month"> Month </label></span><span class="form-sub-label-container"><input class="noDefault form-textbox validate[required]" id="day_25" name="q25_startDate25[day]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  127.             <label class="form-sub-label" for="day_25" id="sublabel_day"> Day </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="year_25" name="q25_startDate25[year]" type="tel" size="4" maxlength="4" value="" />
  128.             <label class="form-sub-label" for="year_25" id="sublabel_year"> Year </label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_25_pick" src="http://cdn.jotfor.ms/images/calendar.png" align="absmiddle" />
  129.             <label class="form-sub-label" for="input_25_pick"> &nbsp;&nbsp;&nbsp; </label></span>
  130.         </div>
  131.       </li>
  132.       <li class="form-line form-line-column" id="id_86">
  133.         <label class="form-label-top" id="label_86" for="input_86">
  134.           End Date of Trip<span class="form-required">*</span>
  135.         </label>
  136.         <div id="cid_86" class="form-input-wide"><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="month_86" name="q86_endDate[month]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  137.             <label class="form-sub-label" for="month_86" id="sublabel_month"> Month </label></span><span class="form-sub-label-container"><input class="noDefault form-textbox validate[required]" id="day_86" name="q86_endDate[day]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  138.             <label class="form-sub-label" for="day_86" id="sublabel_day"> Day </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="year_86" name="q86_endDate[year]" type="tel" size="4" maxlength="4" value="" />
  139.             <label class="form-sub-label" for="year_86" id="sublabel_year"> Year </label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_86_pick" src="http://cdn.jotfor.ms/images/calendar.png" align="absmiddle" />
  140.             <label class="form-sub-label" for="input_86_pick"> &nbsp;&nbsp;&nbsp; </label></span>
  141.         </div>
  142.       </li>
  143.       <li class="form-line" id="id_24">
  144.         <label class="form-label-top" id="label_24" for="input_24">
  145.           Billing/Mailing Street Address<span class="form-required">*</span>
  146.         </label>
  147.         <div id="cid_24" class="form-input-wide">
  148.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_24" name="q24_billingmailingStreet" size="70" value="" />
  149.         </div>
  150.       </li>
  151.       <li class="form-line form-line-column" id="id_66">
  152.         <label class="form-label-top" id="label_66" for="input_66">
  153.           City<span class="form-required">*</span>
  154.         </label>
  155.         <div id="cid_66" class="form-input-wide">
  156.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_66" name="q66_city" size="76" value="" />
  157.         </div>
  158.       </li>
  159.       <li class="form-line form-line-column" id="id_67">
  160.         <label class="form-label-top" id="label_67" for="input_67">
  161.           State<span class="form-required">*</span>
  162.         </label>
  163.         <div id="cid_67" class="form-input-wide">
  164.           <input type="text" class=" form-textbox validate[required, Alphabetic]" data-type="input-textbox" id="input_67" name="q67_state67" size="2" value="" />
  165.         </div>
  166.       </li>
  167.       <li class="form-line form-line-column" id="id_68">
  168.         <label class="form-label-top" id="label_68" for="input_68">
  169.           Zip Code<span class="form-required">*</span>
  170.         </label>
  171.         <div id="cid_68" class="form-input-wide">
  172.           <input type="text" class=" form-textbox validate[required, Numeric]" data-type="input-textbox" id="input_68" name="q68_zipCode" size="5" value="" />
  173.         </div>
  174.       </li>
  175.       <li class="form-line form-line-column" id="id_14">
  176.         <label class="form-label-top" id="label_14" for="input_14">
  177.           Email Address<span class="form-required">*</span>
  178.         </label>
  179.         <div id="cid_14" class="form-input-wide">
  180.           <input type="email" class=" form-textbox validate[required, Email]" id="input_14" name="q14_emailAddress" size="40" value="" />
  181.         </div>
  182.       </li>
  183.       <li class="form-line form-line-column" id="id_69">
  184.         <label class="form-label-top" id="label_69" for="input_69">
  185.           Occupation/Employer<span class="form-required">*</span>
  186.         </label>
  187.         <div id="cid_69" class="form-input-wide">
  188.           <input type="email" class=" form-textbox validate[required]" id="input_69" name="q69_occupationemployer69" size="60" value="" />
  189.         </div>
  190.       </li>
  191.       <li class="form-line form-line-column" id="id_17">
  192.         <label class="form-label-top" id="label_17" for="input_17">
  193.           HOME PHONE<span class="form-required">*</span>
  194.         </label>
  195.         <div id="cid_17" class="form-input-wide"><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="tel" name="q17_homePhone[area]" id="input_17_area" size="3">
  196.             -
  197.             <label class="form-sub-label" for="input_17_area" id="sublabel_area"> Area Code </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="tel" name="q17_homePhone[phone]" id="input_17_phone" size="8">
  198.             <label class="form-sub-label" for="input_17_phone" id="sublabel_phone"> Phone Number </label></span>
  199.         </div>
  200.       </li>
  201.       <li class="form-line form-line-column" id="id_59">
  202.         <label class="form-label-top" id="label_59" for="input_59"> WORK PHONE </label>
  203.         <div id="cid_59" class="form-input-wide"><span class="form-sub-label-container"><input class="form-textbox" type="tel" name="q59_workPhone[area]" id="input_59_area" size="3">
  204.             -
  205.             <label class="form-sub-label" for="input_59_area" id="sublabel_area"> Area Code </label></span><span class="form-sub-label-container"><input class="form-textbox" type="tel" name="q59_workPhone[phone]" id="input_59_phone" size="8">
  206.             <label class="form-sub-label" for="input_59_phone" id="sublabel_phone"> Phone Number </label></span>
  207.         </div>
  208.       </li>
  209.       <li class="form-line form-line-column" id="id_60">
  210.         <label class="form-label-top" id="label_60" for="input_60"> CELL PHONE </label>
  211.         <div id="cid_60" class="form-input-wide"><span class="form-sub-label-container"><input class="form-textbox" type="tel" name="q60_cellPhone60[area]" id="input_60_area" size="3">
  212.             -
  213.             <label class="form-sub-label" for="input_60_area" id="sublabel_area"> Area Code </label></span><span class="form-sub-label-container"><input class="form-textbox" type="tel" name="q60_cellPhone60[phone]" id="input_60_phone" size="8">
  214.             <label class="form-sub-label" for="input_60_phone" id="sublabel_phone"> Phone Number </label></span>
  215.         </div>
  216.       </li>
  217.       <li class="form-line form-line-column" id="id_63">
  218.         <label class="form-label-top" id="label_63" for="input_63"> BIRTHPLACE </label>
  219.         <div id="cid_63" class="form-input-wide">
  220.           <input type="text" class=" form-textbox" data-type="input-textbox" id="input_63" name="q63_birthplace63" size="60" value="" />
  221.         </div>
  222.       </li>
  223.       <li class="form-line form-line-column" id="id_62">
  224.         <label class="form-label-top" id="label_62" for="input_62">
  225.           BIRTH DATE<span class="form-required">*</span>
  226.         </label>
  227.         <div id="cid_62" class="form-input-wide"><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="month_62" name="q62_birthDate[month]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  228.             <label class="form-sub-label" for="month_62" id="sublabel_month"> Month </label></span><span class="form-sub-label-container"><input class="noDefault form-textbox validate[required]" id="day_62" name="q62_birthDate[day]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  229.             <label class="form-sub-label" for="day_62" id="sublabel_day"> Day </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="year_62" name="q62_birthDate[year]" type="tel" size="4" maxlength="4" value="" />
  230.             <label class="form-sub-label" for="year_62" id="sublabel_year"> Year </label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_62_pick" src="http://cdn.jotfor.ms/images/calendar.png" align="absmiddle" />
  231.             <label class="form-sub-label" for="input_62_pick"> &nbsp;&nbsp;&nbsp; </label></span>
  232.         </div>
  233.       </li>
  234.       <li class="form-line form-line-column" id="id_64">
  235.         <label class="form-label-top" id="label_64" for="input_64"> BODY WEIGHT (FOR FLIGHTS) </label>
  236.         <div id="cid_64" class="form-input-wide">
  237.           <input type="text" class=" form-textbox validate[Numeric]" data-type="input-textbox" id="input_64" name="q64_bodyWeight64" size="20" value="" />
  238.         </div>
  239.       </li>
  240.       <li class="form-line form-line-column" id="id_70">
  241.         <label class="form-label-top" id="label_70" for="input_70"> Passport # </label>
  242.         <div id="cid_70" class="form-input-wide">
  243.           <input type="text" class=" form-textbox" data-type="input-textbox" id="input_70" name="q70_passport" size="20" value="" />
  244.         </div>
  245.       </li>
  246.       <li class="form-line form-line-column form-line-column-clear" id="id_71">
  247.         <label class="form-label-top" id="label_71" for="input_71"> Date Issued </label>
  248.         <div id="cid_71" class="form-input-wide"><span class="form-sub-label-container"><input class="form-textbox" id="month_71" name="q71_dateIssued[month]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  249.             <label class="form-sub-label" for="month_71" id="sublabel_month"> Month </label></span><span class="form-sub-label-container"><input class="noDefault form-textbox" id="day_71" name="q71_dateIssued[day]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  250.             <label class="form-sub-label" for="day_71" id="sublabel_day"> Day </label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_71" name="q71_dateIssued[year]" type="tel" size="4" maxlength="4" value="" />
  251.             <label class="form-sub-label" for="year_71" id="sublabel_year"> Year </label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_71_pick" src="http://cdn.jotfor.ms/images/calendar.png" align="absmiddle" />
  252.             <label class="form-sub-label" for="input_71_pick"> &nbsp;&nbsp;&nbsp; </label></span>
  253.         </div>
  254.       </li>
  255.       <li class="form-line form-line-column" id="id_72">
  256.         <label class="form-label-top" id="label_72" for="input_72"> Expiration Date </label>
  257.         <div id="cid_72" class="form-input-wide"><span class="form-sub-label-container"><input class="form-textbox" id="month_72" name="q72_expirationDate[month]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  258.             <label class="form-sub-label" for="month_72" id="sublabel_month"> Month </label></span><span class="form-sub-label-container"><input class="noDefault form-textbox" id="day_72" name="q72_expirationDate[day]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  259.             <label class="form-sub-label" for="day_72" id="sublabel_day"> Day </label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_72" name="q72_expirationDate[year]" type="tel" size="4" maxlength="4" value="" />
  260.             <label class="form-sub-label" for="year_72" id="sublabel_year"> Year </label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_72_pick" src="http://cdn.jotfor.ms/images/calendar.png" align="absmiddle" />
  261.             <label class="form-sub-label" for="input_72_pick"> &nbsp;&nbsp;&nbsp; </label></span>
  262.         </div>
  263.       </li>
  264.       <li class="form-line form-line-column" id="id_73">
  265.         <label class="form-label-top" id="label_73" for="input_73">
  266.           Emergency contact<span class="form-required">*</span>
  267.         </label>
  268.         <div id="cid_73" class="form-input-wide">
  269.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_73" name="q73_emergencyContact73" size="60" value="" />
  270.         </div>
  271.       </li>
  272.       <li class="form-line form-line-column" id="id_74">
  273.         <label class="form-label-top" id="label_74" for="input_74">
  274.           Relationship<span class="form-required">*</span>
  275.         </label>
  276.         <div id="cid_74" class="form-input-wide">
  277.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_74" name="q74_relationship" size="20" value="" />
  278.         </div>
  279.       </li>
  280.       <li class="form-line form-line-column" id="id_75">
  281.         <label class="form-label-top" id="label_75" for="input_75">
  282.           Emergency contact home number<span class="form-required">*</span>
  283.         </label>
  284.         <div id="cid_75" class="form-input-wide"><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="tel" name="q75_emergencyContact75[area]" id="input_75_area" size="3">
  285.             -
  286.             <label class="form-sub-label" for="input_75_area" id="sublabel_area"> Area Code </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="tel" name="q75_emergencyContact75[phone]" id="input_75_phone" size="8">
  287.             <label class="form-sub-label" for="input_75_phone" id="sublabel_phone"> Phone Number </label></span>
  288.         </div>
  289.       </li>
  290.       <li class="form-line form-line-column" id="id_76">
  291.         <label class="form-label-top" id="label_76" for="input_76"> Emergency contact work number </label>
  292.         <div id="cid_76" class="form-input-wide"><span class="form-sub-label-container"><input class="form-textbox" type="tel" name="q76_emergencyContact[area]" id="input_76_area" size="3">
  293.             -
  294.             <label class="form-sub-label" for="input_76_area" id="sublabel_area"> Area Code </label></span><span class="form-sub-label-container"><input class="form-textbox" type="tel" name="q76_emergencyContact[phone]" id="input_76_phone" size="8">
  295.             <label class="form-sub-label" for="input_76_phone" id="sublabel_phone"> Phone Number </label></span>
  296.         </div>
  297.       </li>
  298.       <li class="form-line" id="id_77">
  299.         <label class="form-label-top" id="label_77" for="input_77">
  300.           Please describe any pre-existing medical conditions or limitations that the lodge should be aware of:<span class="form-required">*</span>
  301.         </label>
  302.         <div id="cid_77" class="form-input-wide">
  303.           <textarea id="input_77" class="form-textarea validate[required]" name="q77_pleaseDescribe77" cols="40" rows="6"></textarea>
  304.         </div>
  305.       </li>
  306.       <li class="form-line" id="id_78">
  307.         <label class="form-label-top" id="label_78" for="input_78">
  308.           Please describe all dietary requirements/preferences/requests as well any allergies that the lodge should be aware of:<span class="form-required">*</span>
  309.         </label>
  310.         <div id="cid_78" class="form-input-wide">
  311.           <textarea id="input_78" class="form-textarea validate[required]" name="q78_pleaseDescribe" cols="40" rows="6"></textarea>
  312.         </div>
  313.       </li>
  314.       <li class="form-line" id="id_29">
  315.         <label class="form-label-top" id="label_29" for="input_29">
  316.           Difficulty walking or getting in and out of boats?<span class="form-required">*</span>
  317.         </label>
  318.         <div id="cid_29" class="form-input-wide">
  319.           <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_29_0" name="q29_difficultyWalking" value="Yes" />
  320.               <label for="input_29_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_29_1" name="q29_difficultyWalking" value="No" />
  321.               <label for="input_29_1"> No </label></span><span class="clearfix"></span>
  322.           </div>
  323.         </div>
  324.       </li>
  325.       <li class="form-line" id="id_30">
  326.         <label class="form-label-top" id="label_30" for="input_30">
  327.           Accommodations<span class="form-required">*</span>
  328.         </label>
  329.         <div id="cid_30" class="form-input-wide">
  330.           <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_30_0" name="q30_accommodations" value="Single Room" />
  331.               <label for="input_30_0"> Single Room </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_30_1" name="q30_accommodations" value="Double Room" />
  332.               <label for="input_30_1"> Double Room </label></span><span class="clearfix"></span>
  333.           </div>
  334.         </div>
  335.       </li>
  336.       <li class="form-line" id="id_79">
  337.         <label class="form-label-top" id="label_79" for="input_79">
  338.           Roommate request/rooming with:<span class="form-required">*</span>
  339.         </label>
  340.         <div id="cid_79" class="form-input-wide">
  341.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_79" name="q79_roommateRequestrooming79" size="20" value="" />
  342.         </div>
  343.       </li>
  344.       <li class="form-line" id="id_31">
  345.         <label class="form-label-top" id="label_31" for="input_31">
  346.           Fishing Ability<span class="form-required">*</span>
  347.         </label>
  348.         <div id="cid_31" class="form-input-wide">
  349.           <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_31_0" name="q31_fishingAbility" value="First time" />
  350.               <label for="input_31_0"> First time </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_31_1" name="q31_fishingAbility" value="Novice" />
  351.               <label for="input_31_1"> Novice </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_31_2" name="q31_fishingAbility" value="Intermediate" />
  352.               <label for="input_31_2"> Intermediate </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_31_3" name="q31_fishingAbility" value="Experienced" />
  353.               <label for="input_31_3"> Experienced </label></span><span class="clearfix"></span>
  354.           </div>
  355.         </div>
  356.       </li>
  357.       <li class="form-line" id="id_80">
  358.         <label class="form-label-top" id="label_80" for="input_80">
  359.           Do you need rental gear?<span class="form-required">*</span>
  360.         </label>
  361.         <div id="cid_80" class="form-input-wide">
  362.           <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_80_0" name="q80_doYou" value="Yes" />
  363.               <label for="input_80_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_80_1" name="q80_doYou" value="No" />
  364.               <label for="input_80_1"> No </label></span><span class="clearfix"></span>
  365.           </div>
  366.         </div>
  367.       </li>
  368.       <li class="form-line" id="id_81">
  369.         <label class="form-label-top" id="label_81" for="input_81"> Please list any rental gear / equipment requests for your trip ( Please note that equiment is not availabe at all destinations. Please confirm before your trip.) </label>
  370.         <div id="cid_81" class="form-input-wide">
  371.           <input type="text" class=" form-textbox" data-type="input-textbox" id="input_81" name="q81_pleaseList81" size="80" value="" />
  372.         </div>
  373.       </li>
  374.       <li class="form-line" id="id_82">
  375.         <label class="form-label-top" id="label_82" for="input_82"> Any special requests for the lodge? </label>
  376.         <div id="cid_82" class="form-input-wide">
  377.           <input type="text" class=" form-textbox" data-type="input-textbox" id="input_82" name="q82_anySpecial" size="80" value="" />
  378.         </div>
  379.       </li>
  380.       <li class="form-line" id="id_83">
  381.         <label class="form-label-top" id="label_83" for="input_83"> Any special requests for your fishing guide? </label>
  382.         <div id="cid_83" class="form-input-wide">
  383.           <input type="text" class=" form-textbox" data-type="input-textbox" id="input_83" name="q83_anySpecial83" size="80" value="" />
  384.         </div>
  385.       </li>
  386.       <li class="form-line" id="id_84">
  387.         <label class="form-label-top" id="label_84" for="input_84"> Please list any accommodations and hotel/transfer information (if any) in area/country prior to the Yellow Dog portion of your trip: </label>
  388.         <div id="cid_84" class="form-input-wide">
  389.           <textarea id="input_84" class="form-textarea" name="q84_pleaseList84" cols="40" rows="6"></textarea>
  390.         </div>
  391.       </li>
  392.       <li class="form-line" id="id_89">
  393.         <label class="form-label-top" id="label_89" for="input_89">
  394.           Please tell us how you heard about Yellow Dog Flyfishing Adventures:<span class="form-required">*</span>
  395.         </label>
  396.         <div id="cid_89" class="form-input-wide">
  397.           <select class="form-dropdown validate[required]" style="width:200px" id="input_89" name="q89_pleaseTell89">
  398.             <option value="">  </option>
  399.             <option value="Internet (Web Site)"> Internet (Web Site) </option>
  400.             <option value="Magazine Advertisement"> Magazine Advertisement </option>
  401.             <option value="Fly Fishing Show"> Fly Fishing Show </option>
  402.             <option value="Friend Referral"> Friend Referral </option>
  403.             <option value="Newsletter"> Newsletter </option>
  404.             <option value="Other"> Other </option>
  405.           </select>
  406.         </div>
  407.       </li>
  408.       <li class="form-line" id="id_88">
  409.         <label class="form-label-top" id="label_88" for="input_88"> Do you currently work with and patronize a speciality fly shop or retailer? </label>
  410.         <div id="cid_88" class="form-input-wide">
  411.           <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_88_0" name="q88_doYou88" value="Yes" />
  412.               <label for="input_88_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_88_1" name="q88_doYou88" value="No" />
  413.               <label for="input_88_1"> No </label></span><span class="clearfix"></span>
  414.           </div>
  415.         </div>
  416.       </li>
  417.       <li class="form-line" id="id_87">
  418.         <label class="form-label-top" id="label_87" for="input_87"> Please tell us the name of your regular fly shop: </label>
  419.         <div id="cid_87" class="form-input-wide">
  420.           <input type="text" class=" form-textbox" data-type="input-textbox" id="input_87" name="q87_pleaseTell" size="50" value="" />
  421.         </div>
  422.       </li>
  423.       <li class="form-line" id="id_90">
  424.         <label class="form-label-top" id="label_90" for="input_90"> Have you read and do you accept the Yellow Dog Flyfishing Adventures LLC terms and conditions, responsibility clauses and cancellation/refund policies? </label>
  425.         <div id="cid_90" class="form-input-wide">
  426.           <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_90_0" name="q90_haveYou" value="Yes" />
  427.               <label for="input_90_0"> Yes </label></span><span class="clearfix"></span>
  428.           </div>
  429.         </div>
  430.       </li>
  431.       <li class="form-line" id="id_85">
  432.         <label class="form-label-top" id="label_85" for="input_85"> Today's Date </label>
  433.         <div id="cid_85" class="form-input-wide"><span class="form-sub-label-container"><input class="form-textbox" id="month_85" name="q85_todaysDate[month]" type="tel" size="2" maxlength="2" value="10" /><span class="date-separate">&nbsp;/</span>
  434.             <label class="form-sub-label" for="month_85" id="sublabel_month"> Month </label></span><span class="form-sub-label-container"><input class="form-textbox" id="day_85" name="q85_todaysDate[day]" type="tel" size="2" maxlength="2" value="24" /><span class="date-separate">&nbsp;/</span>
  435.             <label class="form-sub-label" for="day_85" id="sublabel_day"> Day </label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_85" name="q85_todaysDate[year]" type="tel" size="4" maxlength="4" value="2013" />
  436.             <label class="form-sub-label" for="year_85" id="sublabel_year"> Year </label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_85_pick" src="http://cdn.jotfor.ms/images/calendar.png" align="absmiddle" />
  437.             <label class="form-sub-label" for="input_85_pick"> &nbsp;&nbsp;&nbsp; </label></span>
  438.         </div>
  439.       </li>
  440.       <li class="form-line" id="id_16">
  441.         <label class="form-label-top" id="label_16" for="input_16">
  442.           Enter the message as it's shown<span class="form-required">*</span>
  443.         </label>
  444.         <div id="cid_16" class="form-input-wide">
  445.           <div class="form-captcha">
  446.             <label for="input_16"> <img alt="Captcha - Reload if it's not displayed" id="input_16_captcha" class="form-captcha-image" style="background:url(http://cdn.jotfor.ms/images/loader-big.gif) no-repeat center;" src="http://cdn.jotfor.ms/images/blank.gif" width="150" height="41" /> </label>
  447.             <div style="white-space:nowrap;">
  448.               <input type="text" id="input_16" class="form-textbox validate[required]" name="captcha" style="width:130px;" />
  449.               <img src="http://cdn.jotfor.ms/images/reload.png" alt="Reload" align="absmiddle" style="cursor:pointer" onclick="JotForm.reloadCaptcha('input_16');" />
  450.               <input type="hidden" name="captcha_id" id="input_16_captcha_id" value="0" />
  451.             </div>
  452.           </div>
  453.         </div>
  454.       </li>
  455.       <li class="form-line" id="id_2">
  456.         <div id="cid_2" class="form-input-wide">
  457.           <div style="text-align:center" class="form-buttons-wrapper">
  458.             <button id="input_2" type="submit" class="form-submit-button form-submit-button-black_blue">
  459.               Click to send to Yellow Dog Fly Fishing Adventures
  460.             </button>
  461.           </div>
  462.         </div>
  463.       </li>
  464.       <li style="clear:both">
  465.       </li>
  466.       <li style="display:none">
  467.         Should be Empty:
  468.         <input type="text" name="website" value="" />
  469.       </li>
  470.     </ul>
  471.   </div>
  472.   <input type="hidden" id="simple_spc" name="simple_spc" value="31644453340145" />
  473.   <script type="text/javascript">
  474.   document.getElementById("si" + "mple" + "_spc").value = "31644453340145-31644453340145";
  475.   </script>
  476. </form></body>
  477. </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!