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volunForm.php

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Sep 4th, 2014
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  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>
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