Untitled

<?php
$Snumber = $_POST["Snumber"];
$Lname = $_POST["Lname"];
$approved = $_POST["approved"];
$activity = $_POST["activity"];
$month = $_POST["month"];
$day = $_POST["day"];
$year = $_POST["year"];
$hours = $_POST["hours"];
$Sname = $_POST["Sname"];
$email = $_POST["email"];
$phone = $_POST["phone"];
if (!isset($_POST['submit'])) { // if page is not submitted to itself echo the form

//multiple recipients
$to = "[email protected]";
$to = "$email";

$subject= "Community Service Conformation";

$message="
echo "We have recieved that ".$Lname.",".$Snumber." has completed ".$activity." on ".$day.",".$month.",".$year." for ".$hours." hours. <br/>";
echo "Please confirm that you are ".$Sname." and had supervised this project. Please foward this email to [email protected]";
";

$headers='MIME-Version: 1.0'. "\r\n";
$headers.='Content-type: text/html; charset=iso-8859-1'. "\r\n";

$headers .= 'To:Supervisor <$email>, Mrs. Ullery <[email protected]>'."\r\n";
$headers .= 'From: Mrs Ullery <[email protected]>'."\r\n";
$headers .= 'Cc: [email protected]'. "\r\n";
$headers .= 'Bcc: [email protected]'. "\r\n";

mail($to, $subject, $message, headers);
?>

<html>
<head>
<title>Habits of the Heart</title>
</head>
<body>
<h1 style="text-align:center"> Habits of the Heart Online Form </h1>
<p style="text-align:center"> By filling out this information, you are stating that you are currently enrolled at Lee's Summit West High School, where community service hours are required for graduation. Community service is defined as volunteer work for which no other credit or monetary compensation is recieved.</p>
<form method="post" action="<?php echo $PHP_SELF;?>">
<b>Student Number:</b><input type="text" size="12" maxlength="7" name="Snumber"><br/><br/>
<b>Legal Name:</b><input type="text" size="12" maxlength="36" name="Lname">:<br /> <br/>

<b>Was your project approved?</b><br />
Yes:<input type="radio" value="Yes" name="approved"><br />
No:<input type="radio" value="No" name="approved"><br /><br/>

<b>Activity Description: </b><br/>
<textarea rows="5" cols="20" name="activity" wrap="physical">What did you do and where did you do it?</textarea>:<br /><br/>
<b>Date of Service</b><br/>
Month:
<select name="month">
<option value="Jan">Jan</option>
<option value="Feb">Feb</option>
<option value="Mar">Mar</option>
<option value="Apr">Apr</option>
<option value="May">May</option>
<option value="Jun">Jun</option>
<option value="July">July</option>
<option value="Aug">Aug</option>
<option value="Sep">Sep</option>
<option value="Oct">Oct</option>
<option value="Nov">Nov</option>
<option value="Dec">Dec</option></select>&nbsp;
Day:
<select name="day">
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option></select>:
Year:
<select name="year">
<option value="2006">2006</option>
<option value="2007">2007</option>
<option value="2008">2008</option>
<option value="2009">2009</option>
<option value="2010">2010</option></select></br><br/>
<b>Number of hours completed:</b><input type="text" size="12" maxlength="12" name="hours"><br /><br/>
<b>Supervisor's Name:</b><input type="text" size="12" maxlength="36" name="Sname"><br /><br/>
<b>Supervisor's Email Address:</b><input type="text" size="12" maxlength="40" name="email"><br /><br/>
<b>Supervisor's Phone Number:</b><input type="text" size="12" maxlength="10" name="phone"><br /><br/>
<input type="submit" value="submit" name="submit">
</form>