API tools faq
paste
View difference between Paste ID: CfkME775 and Z65L7dZu
SHOW: | | - or go back to the newest paste.
1
<?php
2-
session_start();
2+
include'authorize.php';
3
if(!isset($_SESSION['sess_user_id']) || (trim($_SESSION['sess_user_id']) == '')) {
4-
	header("location: login.php");
4+
	redirect("login.php");
5
	exit();
6
}
7
?>
8
<!DOCTYPE html>
9
<html>
10-
    <head>
10+
<head>
11-
        <meta charset="UTF-8">
11+
<meta charset="UTF-8">
12-
        <title>Volunteer Database</title>
12+
<title>Volunteer Database</title>
13-
        <script type="text/javascript" src="js/functions.js"> </script>
13+
<script type="text/javascript" src="js/functions.js"> </script>
14-
        <link rel="stylesheet" href="css/bootstrap-theme.css" type="text/css" />
14+
<link rel="stylesheet" href="css/bootstrap-theme.css" type="text/css" />
15-
        <link rel="stylesheet" href="css/bootstrap.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">
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>
17+
<script src="http://code.jquery.com/jquery-latest.min.js" type="text/javascript"></script>
18-
    </head>
18+
</head>
19-
    <body>
19+
<body>
20-
        <div class="sidebar">
20+
<div class="sidebar">
21-
            <ul class="nav nav-pills nav-stacked">
21+
		<ul class="nav nav-pills nav-stacked">
22-
                <li>Welcome  <?php echo $_SESSION["sess_name"] ?></li>
22+
				<li>Welcome <?php echo $_SESSION["sess_name"] ?></li>
23-
                <li><a href="logout.php">Logout</a></li>
23+
				<li><a href="logout.php">Logout</a></li>
24-
                <li><a href="home.php">Home</a><li>
24+
				<li><a href="home.php">Home</a>
25-
                <li class="active"><a href="volunForm.php">Add Volunteer</a></li>
25+
				<li>
26-
                <li><a href="search.php">Search/Report</a></li>
26+
				<li class="active"><a href="volunForm.php">Add Volunteer</a></li>
27-
                <li><a href="allVolun.php">View Volunteers</a></li>
27+
				<li><a href="search.php">Search/Report</a></li>
28-
                <li><a href="updateVolunteer.php">Update Volunteer</a></li>
28+
				<li><a href="allVolun.php">View Volunteers</a></li>
29-
29+
				<li><a href="updateVolunteer.php">Update Volunteer</a></li>
30-
            </ul>
30+
		</ul>
31-
        </div>
31+
</div>
32-
        <div class="content">
32+
<div class="content"> <br>
33-
        <br><br><br>
33+
		<br>
34-
        <form action="add.php" method="post">
34+
		<br>
35-
        <center><table style="border:1px solid black; width:850px; padding:2px;">
35+
		<form action="add.php" method="post">
36-
           <tr>
36+
				<div align="CENTER">
37-
               <td><label>First Name:</label></td><td><input type="text" name="fname" id="fname" /></td>
37+
				<table style="border:1px solid black; width:850px; padding:2px;">
38-
           <td><label>Middle Initial:</label></td><td><input type="text" name="middle" id="middle" /></td>
38+
						<tr>
39-
           <td><label>Last Name:</label></td><td><input type="text" name="lname" id="lname" /></td></tr>
39+
								<td><label>First Name:</label></td>
40-
            <tr><td><label>Street Address:</label></td><td colspan="3"><input type="text" name="address" id="address" style="width:320px;" /></td>
40+
								<td><input type="text" name="fname" id="fname" /></td>
41-
            <td><label>City:</label></td><td><input type="text" name="city" id="city" /></td></tr>
41+
								<td><label>Middle Initial:</label></td>
42-
            <tr><td><label>State:</label></td><td><input type="text" name="state" id="state" /></td>
42+
								<td><input type="text" name="middle" id="middle" /></td>
43-
                <td><label>ZIP:</label></td><td><input type="text" name="zip" id="zip" /></td>
43+
								<td><label>Last Name:</label></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>
44+
								<td><input type="text" name="lname" id="lname" /></td>
45-
45+
						</tr>
46-
            <tr><td><label>Mailing Address (If different):</label></td><td colspan="3"><input type="text" name="mailing" id="mailing" style="width:320px;" /></td>
46+
						<tr>
47-
            <td><label>Home Phone:</label></td><td><input type="text" name="hphone" id="hphone" /></td></tr>
47+
								<td><label>Street Address:</label></td>
48-
            <tr><td><label>Mobile Phone:</label></td><td><input type="text" name="mphone" id="mphone" /></td>
48+
								<td colspan="3"><input type="text" name="address" id="address" style="width:320px;" /></td>
49-
            <td><label>Work Phone:</label></td><td><input type="text" name="wphone" id="wphone" /></td>
49+
								<td><label>City:</label></td>
50-
            <td><label>Ext:</label></td><td><input type="text" name="ext" id="ext" /></td></tr>
50+
								<td><input type="text" name="city" id="city" /></td>
51-
            <tr><td><label>Fax:</label></td><td><input type="text" name="fax" id="fax" /></td>
51+
						</tr>
52-
            <td><label>E-mail:</label></td><td colspan="3"><input type="text" name="email" id="email" style="width:320px;" /></td></tr>
52+
						<tr>
53-
53+
								<td><label>State:</label></td>
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>
54+
								<td><input type="text" name="state" id="state" /></td>
55-
55+
								<td><label>ZIP:</label></td>

56-
            <td><label>Specify if other:</label></td><td colspan="3"><input type="text" name="other1" id="other1" style="width:320px;" /></td></tr>

56+
								<td><input type="text" name="zip" id="zip" /></td>

57-
            <tr><td><label>Occupation:</label></td><td colspan="1" width="200px"><input type="text" name="occupation" id="occupation" style="width:200px;" /></td>

57+
								<td><label>County:</label></td>

58-
            <td><label>Place of Employment:</label></td><td colspan="3"><input type="text" name="poe" id="poe" style="width:200px" /></td></tr>

58+
								<td><select name="county" id="county">

59-
            <tr><td><label>Date of Birth:</label></td><td><input type="date" name="dob" id="dob" /></td>

59+
												<option>Butler</option>

60-
            

60+
												<option>Cass</option>

61-
                <td><label>Gender:</label></td><td colspan="3"><select id="gender" name="gender"><option>Female</option><option>Male</option></select></td></tr>

61+
												<option>Fillmore</option>

62-
            <tr><td><label>Disaster Volunteer:</label></td><td><input type="checkbox" id="disastervoln" name="bhv" value="BHV"><b>BHV</b></td>

62+
												<option>Gage</option>

63-
                <td><input type="checkbox" id="disastervoln" name="mrc" value="MRC"><b>MRC</b></td>

63+
												<option>Jefferson</option>

64-
                <td><input type="checkbox" id="disastervoln" name="general" value="General"><b>General</b></td>

64+
												<option>Johnson</option>

65-
                <td colspan="2"><input type="checkbox" id="disastervoln" name="evv" value="EVV"><b>EVC</b> </td>

65+
												<option>Lancaster</option>

66-
            </table>

66+
												<option>Nemaha</option>

67-
            <table style="border: 1px solid black; width:850px;">

67+
												<option>Otoe</option>

68-
            <tr><td colspan="6"><center><label>Service Counties</label></center></td></tr>

68+
												<option>Pawnee</option>

69-
            <tr><td style="width:141.3px"><input type="checkbox" id="scounty" name="allCounties" value="All"><b>All</b></td>

69+
												<option>Polk</option>

70-
                <td style="width:141.3px"><input type="checkbox" class="scounty" name="fillmore" value="Fillmore"><b>Fillmore</b></td>

70+
												<option>Richardson</option>

71-
                <td style="width:141.3px"><input type="checkbox" class="scounty" name="johnson" value="Jonhson"><b>Johnson</b></td>

71+
												<option>Saline</option>

72-
                <td style="width:141.3px"><input type="checkbox" class="scounty" name="otoe" value="Otoe"><b>Otoe</b></td>

72+
												<option>Saunders</option>

73-
                <td style="width:141.3px"><input type="checkbox" class="scounty" name="richardson" value="Richardson"><b>Richardson</b></td>

73+
												<option>Seward</option>

74-
                <td style="width:141.3px"><input type="checkbox" class="scounty" name="seward" value="Seward"><b>Seward</b></td></tr>

74+
												<option>Thayer</option>

75-
            <tr><td><input type="checkbox" class="scounty" name="butler" value="Butler"><b>Butler</b></td>

75+
												<option>York</option>

76-
                <td><input type="checkbox" class="scounty" name="gage" value="Gage"><b>Gage</b></td>

76+
										</select></td>

77-
                <td><input type="checkbox" class="scounty" name="lancaster" value="Lancaster"><b>Lancaster</b></td>

77+
						</tr>

78-
                <td><input type="checkbox" class="scounty" name="pawnee" value="Pawnee"><b>Pawnee</b></td>

78+
						<tr>

79-
                <td><input type="checkbox" class="scounty" name="saline" value="Saline"><b>Saline</b></td>

79+
								<td><label>Mailing Address (If different):</label></td>

80-
                <td><input type="checkbox" class="scounty" name="thayer" value="Thayer"><b>Thayer</b></td></tr>

80+
								<td colspan="3"><input type="text" name="mailing" id="mailing" style="width:320px;" /></td>

81-
            <tr><td><input type="checkbox" class="scounty" name="cass" value="Cass"><b>Cass</b></td>

81+
								<td><label>Home Phone:</label></td>

82-
                <td><input type="checkbox" class="scounty" name="jefferson" value="Jefferson"><b>Jefferson</b></td>

82+
								<td><input type="text" name="hphone" id="hphone" /></td>

83-
                <td><input type="checkbox" class="scounty" name="nemaha" value="Nemaha"><b>Nemaha</b></td>

83+
						</tr>

84-
                <td><input type="checkbox" class="scounty" name="polk" value="Polk"><b>Polk</b></td>

84+
						<tr>

85-
                <td><input type="checkbox" class="scounty" name="saunders" value="Saunders"><b>Saunders</b></td>

85+
								<td><label>Mobile Phone:</label></td>

86-
                <td><input type="checkbox" class="scounty" name="york" value="York"><b>York</b></td>

86+
								<td><input type="text" name="mphone" id="mphone" /></td>

87-
            <tr><td><label>Specify if other</label></td><td colspan="5"><input type="text" name="other2" id="other2" /></td></tr>

87+
								<td><label>Work Phone:</label></td>

88-
            </table>

88+
								<td><input type="text" name="wphone" id="wphone" /></td>

89-
            <table style="width:850px; border: 1px solid black;">

89+
								<td><label>Ext:</label></td>

90-
            <tr><td colspan="6"><center><label>Volunteer Skills</label></center></td></tr>

90+
								<td><input type="text" name="ext" id="ext" /></td>

91-
            <tr><td><input type="checkbox" id="vSkills" name="aro" value="Amateur Radio Operator"><b>Amateur Radio Operator</b></td>

91+
						</tr>

92-
            <td><input type="checkbox" id="vSkills" name="clergy" value="Clergy"><b>Clergy</b></td>

92+
						<tr>

93-
            <td colspan="2"><input type="checkbox" id="vSkills" name="intskills" value="Interpreter Skills"><b>Interpreter Skills</b></td>

93+
								<td><label>Fax:</label></td>

94-
                <td><label>Languages?</label></td>

94+
								<td><input type="text" name="fax" id="fax" /></td>

95-
                    <td colspan="2"><input type="text" name="interpt" id="interpt" /></td></tr>

95+
								<td><label>E-mail:</label></td>

96-
            <tr><td><input type="checkbox" id="vSkills" name="bus" value="Bus/Truck Driver"><b>Bus/Truck Driver</b></td>

96+
								<td colspan="3"><input type="text" name="email" id="email" style="width:320px;" /></td>

97-
                <td><label>Is CDL Current?</label></td>

97+
						</tr>

98-
                        <td><select name="cdl" id="cdl"><option></option><option>Yes</option><option>No</option></select></td>

98+
						<tr>

99-
            <td><input type="checkbox" id="vSkills" name="child" value="Child Care"><b>Child Care</b></td>

99+
								<td><label>Ethnic Group:</label></td>

100-
            <td colspan="2"><input type="checkbox" id="vSkills" name="law" value="Law Enforcement"><b>Law Enforcement</b></td></tr>

100+
								<td><select id="ethgroup" name="ethgroup">

101-
            <tr><td><input type="checkbox" id="vSkills" name="cpr" value="CPR"><b>CPR</b></td>

101+
												<option>African American</option>

102-
                <td><label>Is CPR card Current?</label></td>

102+
												<option>American Indian/Alaska Native</option>

103-
                    <td><select name="cpryn" id="cpryn" ><option></option><option>Yes</option><option>No</option></select></td>

103+
												<option>Asian/Pacific Islander</option>

104-
            <td><input type="checkbox" id="vSkills" name="data" value="Data Entry"><b>Data Entry</b></td>

104+
												<option>Hispanic</option>

105-
            <td colspan="2"><input type="checkbox" id="vSkills" name="security" value="security"><b>Security</b></td></tr>

105+
												<option>White</option>

106-
            <tr><td><input type="checkbox" id="vSkills" name="emergency" value="Emergency Communication"><b>Emergency Communication</b></td> 

106+
												<option>Other</option>

107-
            <td style="width:125px;"><input type="checkbox" id="vSkills" name="computer" value="Computer Skills"><b>Computer Skills</b>  </td>

107+
										</select></td>

108-
            <td><input type="checkbox" id="vSkills" name="mechanical" value="Mechanical Ability"><b>Mechanical Ability</b></td>

108+
								<td><label>Specify if other:</label></td>

109-
            <td colspan="2"><input type="checkbox" id="vSkills" name="administration" value="Administratiion/Office Skills"><b>Administration/Office Skills</b></td></tr>

109+
								<td colspan="3"><input type="text" name="other1" id="other1" style="width:320px;" /></td>

110-
            <tr><td><input type="checkbox" id="vSkills" name="firstaid" value="First Aid"><b>First Aid</b></td>

110+
						</tr>

111-
                <td><label>Is F. Aid Card Current?</label></td>

111+
						<tr>

112-
                <td><select name="faid" id="faid"><option></option><option>Yes</option><option>No</option></select></td>

112+
								<td><label>Occupation:</label></td>

113-
            <td><input type="checkbox" id="vSkills" name="translation" value="Translation Skills"><b>Translation Skills</b></td>

113+
								<td colspan="1" width="200px"><input type="text" name="occupation" id="occupation" style="width:200px;" /></td>

114-
               <td><label>Languages?</label></td>

114+
								<td><label>Place of Employment:</label></td>

115-
                   <td><input type="text" name="translate" id="translate" /></td></tr>

115+
								<td colspan="3"><input type="text" name="poe" id="poe" style="width:200px" /></td>

116-
            <tr><td><input type="checkbox" id="vSkills" name="construction" value="Construction"> <b>Construction</b></td>

116+
						</tr>

117-
            <td><input type="checkbox" id="vSkills" name="basicclean" value="Basic Clean-up Skills"><b>Basic Clean-up Skills</b></td> 

117+
						<tr>

118-
            <td><input type="checkbox" id="vSkills" name="foodprep" value="Food Preparation"><b>Food Preparation</b></td>    

118+
								<td><label>Date of Birth:</label></td>

119-
            <td><input type="checkbox" id="vSkills" name="animalcare" value="Animal Care/Rescue"><b>Animal Care/Rescue</b></td>

119+
								<td><input type="date" name="dob" id="dob" /></td>

120-
            <td colspan="2"><input type="checkbox" id="vSkills" name="heavy" value="Heavy Equipment Operation"><b>Heavy Equipment Operation</b></td></tr>

120+
								<td><label>Gender:</label></td>

121-
            <tr> 

121+
								<td colspan="3"><select id="gender" name="gender">

122-
                <td><label>Specify if other</label></td>

122+
												<option>Female</option>

123-
                    <td colspan="5"><input type="text" name="other3" id="other3" /></td></tr>

123+
												<option>Male</option>

124-
            </table>

124+
										</select></td>

125-
            <table style="width: 850px; border: black 1px solid;">

125+
						</tr>

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>

126+
						<tr>

127-
                <tr><td><label>Verification date</label></td><td><input type="date" name="verf1" id="verf1" /></td>

127+
								<td><label>Disaster Volunteer:</label></td>

128-
                    <td><label>License/Certificate #:</label></td><td><input type="text" name="num1" id="num1" /></td>

128+
								<td><input type="checkbox" id="disastervoln" name="bhv" value="BHV">

129-
                    <td><label>Expiration date</label></td><td><input type="date" name="exp1" id="exp1" /></td></tr>

129+
										<b>BHV</b></td>

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>

130+
								<td><input type="checkbox" id="disastervoln" name="mrc" value="MRC">

131-
                <tr><td><label>Verification date</label></td><td><input type="date" name="verf2" id="verf2" /> </td>

131+
										<b>MRC</b></td>

132-
                    <td><label>License/Certificate #:</label></td><td><input type="text" name="num2" id="num2" /></td>

132+
								<td><input type="checkbox" id="disastervoln" name="general" value="General">

133-
                    <td><label>Expiration date</label></td><td><input type="date" name="exp2" id="exp2" /></td></tr>

133+
										<b>General</b></td>

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>

134+
								<td colspan="2"><input type="checkbox" id="disastervoln" name="evv" value="EVV">

135-
                <tr><td><label>Verification date</label></td><td><input type="date" name="verf3" id="verf3" /></td>

135+
										<b>EVC</b></td>

136-
                    <td><label>License/Certificate #:</label></td><td><input type="text" name="num3" id="num3" /></td>

136+
										</tr>

137-
                    <td><label>Expiration date</label></td><td><input type="date" name="exp3" id="exp3" /></td></tr>

137+
				</table>

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>

138+
				<table style="border: 1px solid black; width:850px;">

139-
                <tr><td><label>Verification date</label></td><td><input type="date" name="verf4" id="verf4" /></td>

139+
						<tr>

140-
                    <td><label>License/Certificate #:</label></td><td><input type="text" name="num4" id="num4" /></td>

140+
								<td colspan="6"><center>

141-
                    <td><label>Expiration date</label></td><td><input type="date" name="exp4" id="exp4" /></td></tr>

141+
												<label>Service Counties</label>

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>

142+
										</center></td>

143-
                <tr><td><label>Verification date</label></td><td><input type="date" name="verf5" id="verf5" /></td>

143+
						</tr>

144-
                    <td><label>License/Certificate #:</label></td><td><input type="text" name="num5" id="num5" /></td>

144+
						<tr>

145-
                    <td><label>Expiration date</label></td><td><input type="date" name="exp5" id="exp5" /></td></tr>

145+
								<td style="width:141.3px"><input type="checkbox" id="scounty" name="allCounties" value="All">

146-
            </table>

146+
										<b>All</b></td>

147-
            <table style="width:850px; border:1px solid black;">

147+
								<td style="width:141.3px"><input type="checkbox" class="scounty" name="fillmore" value="Fillmore">

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>

148+
										<b>Fillmore</b></td>

149-
                    <td><label>Specify if "Yes"</label></td><td><input type="text" name="syes" id="syes" /></td></tr>

149+
								<td style="width:141.3px"><input type="checkbox" class="scounty" name="johnson" value="Jonhson">

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>

150+
										<b>Johnson</b></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>

151+
								<td style="width:141.3px"><input type="checkbox" class="scounty" name="otoe" value="Otoe">

152-
            </table>

152+
										<b>Otoe</b></td>

153-
            <table style="width:850px; border:1px solid black;">

153+
								<td style="width:141.3px"><input type="checkbox" class="scounty" name="richardson" value="Richardson">

154-
                <tr><td colspan="4"><center><label>EVC Roles</label></center></td></tr>

154+
										<b>Richardson</b></td>

155-
                

155+
								<td style="width:141.3px"><input type="checkbox" class="scounty" name="seward" value="Seward">

156-
                <tr><td><input type="checkbox" id="etrain" name="dataentry" value="Data Entry"><b>Data Entry</b></td>

156+
										<b>Seward</b></td>

157-
                    <td><input type="checkbox" id="etrain" name="identification" value="Identification Staff"><b>Identification staff</b></td>

157+
						</tr>

158-
                    <td><input type="checkbox" id="etrain" name="phone" value="Phone Bank Staff"><b>Phone Bank Staff</b></td>

158+
						<tr>

159-
                    <td><input type="checkbox" id="etrain" name="runner" value="Runner"><b>Runner</b></td></tr>

159+
								<td><input type="checkbox" class="scounty" name="butler" value="Butler">

160-
                    <tr><td><input type="checkbox" id="etrain" name="greeter" value="Greeter"><b>Greeter</b></td>

160+
										<b>Butler</b></td>

161-
                    <td><input type="checkbox" id="etrain" name="interviewer" value="Interviewer"><b>Interviewer</b></td>

161+
								<td><input type="checkbox" class="scounty" name="gage" value="Gage">

162-
                    <td colspan="2"><input type="checkbox" id="etrain" name="safety" value="Safety Orientation"><b>Safety Orientation</b></td></tr>

162+
										<b>Gage</b></td>

163-
            </table>         

163+
								<td><input type="checkbox" class="scounty" name="lancaster" value="Lancaster">

164-
            <table style="width:850px; border: 1px solid black;">

164+
										<b>Lancaster</b></td>

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>

165+
								<td><input type="checkbox" class="scounty" name="pawnee" value="Pawnee">

166-
                    <td><label>Training Date</label></td><td><input type="date" name="tdate1" /></td></tr>

166+
										<b>Pawnee</b></td>

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>

167+
								<td><input type="checkbox" class="scounty" name="saline" value="Saline">

168-
                    <td><label>Training Date</label></td><td><input type="date" name="tdate2" /></td></tr>

168+
										<b>Saline</b></td>

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>

169+
								<td><input type="checkbox" class="scounty" name="thayer" value="Thayer">

170-
                    <td><label>Training Date</label></td><td><input type="date" name="tdate3" /></td></tr>

170+
										<b>Thayer</b></td>

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>

171+
						</tr>

172-
                    <td><label>Training Date</label></td><td><input type="date" name="tdate4" /></td></tr>

172+
						<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>

173+
								<td><input type="checkbox" class="scounty" name="cass" value="Cass">

174-
                    <td><label>Training Date</label></td><td><input type="date" name="tdate5" /></td></tr>

174+
										<b>Cass</b></td>

175-
            </table>

175+
								<td><input type="checkbox" class="scounty" name="jefferson" value="Jefferson">

176-
            <table style="width:850px; border:solid black 1px;">

176+
										<b>Jefferson</b></td>

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>

177+
								<td><input type="checkbox" class="scounty" name="nemaha" value="Nemaha">

178-
                    <td><label>Specify if Yes</label></td><td><input type="text" name="felonys" /></td></tr>

178+
										<b>Nemaha</b></td>

179-
            </table>

179+
								<td><input type="checkbox" class="scounty" name="polk" value="Polk">

180-
            <table style="width:850px; border:solid black 1px;">

180+
										<b>Polk</b></td>

181-
                <tr><td><label>Name:</label></td><td colspan="2"><input type="text" name="ename" /></td>

181+
								<td><input type="checkbox" class="scounty" name="saunders" value="Saunders">

182-
                    <td><label>Relationship:</label></td><td colspan="2"><input type="text" name="erelation" style="width:300px;" /> </td></tr>

182+
										<b>Saunders</b></td>

183-
                <tr><td><label>Home phone:</label></td><td><input type="text" name="ehphone" /></td>

183+
								<td><input type="checkbox" class="scounty" name="york" value="York">

184-
                    <td><label>Mobile phone:</label></td><td><input type="text" name="emphone" /></td>

184+
										<b>York</b></td>

185-
                    <td><label>Address:</label></td><td><input type="text" name="eaddress" /></td></tr>

185+
										</tr>

186-
                <tr><td><label>City:</label></td><td><input type="text" name="ecity" /></td>

186+
						<tr>

187-
                    <td><label>State:</label></td><td><input type="text" name="estate" /></td>

187+
								<td><label>Specify if other</label></td>

188-
                    <td><label>Zip:</label></td><td><input type="text" name="ezip" /></td></tr>

188+
								<td colspan="5"><input type="text" name="other2" id="other2" /></td>

189-
            </table>

189+
						</tr>

190-
            <table style="width:850px; border:solid black 1px;">

190+
				</table>

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>

191+
				<table style="width:850px; border: 1px solid black;">

192-
                <tr><td><label>Brief description and other info</label></td><td><input type="text" name="bdesc" style="width:300px;" /> </td></tr>

192+
						<tr>

193-
            </table>

193+
								<td colspan="6"><center>

194-
            <input type="submit" class="btn btn-primary" value="Submit" />

194+
												<label>Volunteer Skills</label>

195-
       </form>

195+
										</center></td>

196-
</center>

196+
						</tr>

197-
            <br><br><br>

197+
						<tr>

198-
            </div>

198+
								<td><input type="checkbox" id="vSkills" name="aro" value="Amateur Radio Operator">

199-
    </body>

199+
										<b>Amateur Radio Operator</b></td>

200
								<td><input type="checkbox" id="vSkills" name="clergy" value="Clergy">

201
										<b>Clergy</b></td>

202
								<td colspan="2"><input type="checkbox" id="vSkills" name="intskills" value="Interpreter Skills">

203
										<b>Interpreter Skills</b></td>

204
								<td><label>Languages?</label></td>

205
								<td colspan="2"><input type="text" name="interpt" id="interpt" /></td>

206
						</tr>

207
						<tr>

208
								<td><input type="checkbox" id="vSkills" name="bus" value="Bus/Truck Driver">

209
										<b>Bus/Truck Driver</b></td>

210
								<td><label>Is CDL Current?</label></td>

211
								<td><select name="cdl" id="cdl">

212
												<option></option>

213
												<option>Yes</option>

214
												<option>No</option>

215
										</select></td>

216
								<td><input type="checkbox" id="vSkills" name="child" value="Child Care">

217
										<b>Child Care</b></td>

218
								<td colspan="2"><input type="checkbox" id="vSkills" name="law" value="Law Enforcement">

219
										<b>Law Enforcement</b></td>

220
						</tr>

221
						<tr>

222
								<td><input type="checkbox" id="vSkills" name="cpr" value="CPR">

223
										<b>CPR</b></td>

224
								<td><label>Is CPR card Current?</label></td>

225
								<td><select name="cpryn" id="cpryn" >

226
												<option></option>

227
												<option>Yes</option>

228
												<option>No</option>

229
										</select></td>

230
								<td><input type="checkbox" id="vSkills" name="data" value="Data Entry">

231
										<b>Data Entry</b></td>

232
								<td colspan="2"><input type="checkbox" id="vSkills" name="security" value="security">

233
										<b>Security</b></td>

234
						</tr>

235
						<tr>

236
								<td><input type="checkbox" id="vSkills" name="emergency" value="Emergency Communication">

237
										<b>Emergency Communication</b></td>

238
								<td style="width:125px;"><input type="checkbox" id="vSkills" name="computer" value="Computer Skills">

239
										<b>Computer Skills</b></td>

240
								<td><input type="checkbox" id="vSkills" name="mechanical" value="Mechanical Ability">

241
										<b>Mechanical Ability</b></td>

242
								<td colspan="2"><input type="checkbox" id="vSkills" name="administration" value="Administratiion/Office Skills">

243
										<b>Administration/Office Skills</b></td>

244
						</tr>

245
						<tr>

246
								<td><input type="checkbox" id="vSkills" name="firstaid" value="First Aid">

247
										<b>First Aid</b></td>

248
								<td><label>Is F. Aid Card Current?</label></td>

249
								<td><select name="faid" id="faid">

250
												<option></option>

251
												<option>Yes</option>

252
												<option>No</option>

253
										</select></td>

254
								<td><input type="checkbox" id="vSkills" name="translation" value="Translation Skills">

255
										<b>Translation Skills</b></td>

256
								<td><label>Languages?</label></td>

257
								<td><input type="text" name="translate" id="translate" /></td>

258
						</tr>

259
						<tr>

260
								<td><input type="checkbox" id="vSkills" name="construction" value="Construction">

261
										<b>Construction</b></td>

262
								<td><input type="checkbox" id="vSkills" name="basicclean" value="Basic Clean-up Skills">

263
										<b>Basic Clean-up Skills</b></td>

264
								<td><input type="checkbox" id="vSkills" name="foodprep" value="Food Preparation">

265
										<b>Food Preparation</b></td>

266
								<td><input type="checkbox" id="vSkills" name="animalcare" value="Animal Care/Rescue">

267
										<b>Animal Care/Rescue</b></td>

268
								<td colspan="2"><input type="checkbox" id="vSkills" name="heavy" value="Heavy Equipment Operation">

269
										<b>Heavy Equipment Operation</b></td>

270
						</tr>

271
						<tr>

272
								<td><label>Specify if other</label></td>

273
								<td colspan="5"><input type="text" name="other3" id="other3" /></td>

274
						</tr>

275
				</table>

276
				<table style="width: 850px; border: black 1px solid;">

277
						<tr>

278
								<td colspan="2"><label>1-License/Certificate:</label></td>

279
								<td colspan="4"><select name="license1" id="license1">

280
												<option></option>

281
												<option>Advanced Practical Registered Nurse</option>

282
												<option>Commercial Drivers License</option>

283
												<option>Certified Master Social Worker</option>

284
												<option>Certified Nursing Assistant</option>

285
												<option>Certified Professional Counselor</option>

286
												<option>Certified Registered Nurse Anesthetist</option>

287
												<option>Certified Social Worker</option>

288
												<option>Emergency Medical Technician</option>

289
												<option>Emergency Medical Technician-Intermediate</option>

290
												<option>Emergency Medical Technician-Paramedic</option>

291
												<option>First Responder</option>

292
												<option>Licensed Alcohol and Drug Counselor</option>

293
												<option>Licensed Child Care Provider</option>

294
												<option>Licensed Mental Health Practitioner</option>

295
												<option>Licensed Practical Nurse</option>

296
												<option>Lab Technician</option>

297
												<option>Medication Aid</option>

298
												<option>Medical Doctor</option>

299
												<option>Marriage and Family Therapist</option>

300
												<option>Nurse Aid</option>

301
												<option>NotChoose</option>

302
												<option>Nurse Practitioner</option>

303
												<option>Physician</option>

304
												<option>Physician Assistant</option>

305
												<option>Provisionally Certified Master Social Worker</option>

306
												<option>Pharmacist</option>

307
												<option>Provisional Licensed Alcohol & Drug Counselor</option>

308
												<option>Provisionally Licensed Mental Health Practitioner</option>

309
												<option>Psychiatrist</option>

310
												<option>Provisional Psychologist</option>

311
												<option>Psychologist Assistant</option>

312
												<option>Psychologist </option>

313
												<option>Registered Nurse</option>

314
												<option>Veterinarian</option>

315
												<option>Veterinarian Technician</option>

316
										</select></td>

317
						</tr>

318
						<tr>

319
								<td><label>Verification date</label></td>

320
								<td><input type="date" name="verf1" id="verf1" /></td>

321
								<td><label>License/Certificate #:</label></td>

322
								<td><input type="text" name="num1" id="num1" /></td>

323
								<td><label>Expiration date</label></td>

324
								<td><input type="date" name="exp1" id="exp1" /></td>

325
						</tr>

326
						<tr>

327
								<td colspan="2"><label>2-License/Certificate:</label></td>

328
								<td colspan="4"><select name="license2" id="license2">

329
												<option></option>

330
												<option>Advanced Practical Registered Nurse</option>

331
												<option>Commercial Drivers License</option>

332
												<option>Certified Master Social Worker</option>

333
												<option>Certified Nursing Assistant</option>

334
												<option>Certified Professional Counselor</option>

335
												<option>Certified Registered Nurse Anesthetist</option>

336
												<option>Certified Social Worker</option>

337
												<option>Emergency Medical Technician</option>

338
												<option>Emergency Medical Technician-Intermediate</option>

339
												<option>Emergency Medical Technician-Paramedic</option>

340
												<option>First Responder</option>

341
												<option>Licensed Alcohol and Drug Counselor</option>

342
												<option>Licensed Child Care Provider</option>

343
												<option>Licensed Mental Health Practitioner</option>

344
												<option>Licensed Practical Nurse</option>

345
												<option>Lab Technician</option>

346
												<option>Medication Aid</option>

347
												<option>Medical Doctor</option>

348
												<option>Marriage and Family Therapist</option>

349
												<option>Nurse Aid</option>

350
												<option>NotChoose</option>

351
												<option>Nurse Practitioner</option>

352
												<option>Physician</option>

353
												<option>Physician Assistant</option>

354
												<option>Provisionally Certified Master Social Worker</option>

355
												<option>Pharmacist</option>

356
												<option>Provisional Licensed Alcohol & Drug Counselor</option>

357
												<option>Provisionally Licensed Mental Health Practitioner</option>

358
												<option>Psychiatrist</option>

359
												<option>Provisional Psychologist</option>

360
												<option>Psychologist Assistant</option>

361
												<option>Psychologist </option>

362
												<option>Registered Nurse</option>

363
												<option>Veterinarian</option>

364
												<option>Veterinarian Technician</option>

365
										</select></td>

366
						</tr>

367
						<tr>

368
								<td><label>Verification date</label></td>

369
								<td><input type="date" name="verf2" id="verf2" /></td>

370
								<td><label>License/Certificate #:</label></td>

371
								<td><input type="text" name="num2" id="num2" /></td>

372
								<td><label>Expiration date</label></td>

373
								<td><input type="date" name="exp2" id="exp2" /></td>

374
						</tr>

375
						<tr>

376
								<td colspan="2"><label>3-License/Certificate:</label></td>

377
								<td colspan="4"><select name="license3" id="license3">

378
												<option></option>

379
												<option>Advanced Practical Registered Nurse</option>

380
												<option>Commercial Drivers License</option>

381
												<option>Certified Master Social Worker</option>

382
												<option>Certified Nursing Assistant</option>

383
												<option>Certified Professional Counselor</option>

384
												<option>Certified Registered Nurse Anesthetist</option>

385
												<option>Certified Social Worker</option>

386
												<option>Emergency Medical Technician</option>

387
												<option>Emergency Medical Technician-Intermediate</option>

388
												<option>Emergency Medical Technician-Paramedic</option>

389
												<option>First Responder</option>

390
												<option>Licensed Alcohol and Drug Counselor</option>

391
												<option>Licensed Child Care Provider</option>

392
												<option>Licensed Mental Health Practitioner</option>

393
												<option>Licensed Practical Nurse</option>

394
												<option>Lab Technician</option>

395
												<option>Medication Aid</option>

396
												<option>Medical Doctor</option>

397
												<option>Marriage and Family Therapist</option>

398
												<option>Nurse Aid</option>

399
												<option>NotChoose</option>

400
												<option>Nurse Practitioner</option>

401
												<option>Physician</option>

402
												<option>Physician Assistant</option>

403
												<option>Provisionally Certified Master Social Worker</option>

404
												<option>Pharmacist</option>

405
												<option>Provisional Licensed Alcohol & Drug Counselor</option>

406
												<option>Provisionally Licensed Mental Health Practitioner</option>

407
												<option>Psychiatrist</option>

408
												<option>Provisional Psychologist</option>

409
												<option>Psychologist Assistant</option>

410
												<option>Psychologist </option>

411
												<option>Registered Nurse</option>

412
												<option>Veterinarian</option>

413
												<option>Veterinarian Technician</option>

414
										</select></td>

415
						</tr>

416
						<tr>

417
								<td><label>Verification date</label></td>

418
								<td><input type="date" name="verf3" id="verf3" /></td>

419
								<td><label>License/Certificate #:</label></td>

420
								<td><input type="text" name="num3" id="num3" /></td>

421
								<td><label>Expiration date</label></td>

422
								<td><input type="date" name="exp3" id="exp3" /></td>

423
						</tr>

424
						<tr>

425
								<td colspan="2"><label>4-License/Certificate:</label></td>

426
								<td colspan="4"><select name="license4" id="license4">

427
												<option></option>

428
												<option>Advanced Practical Registered Nurse</option>

429
												<option>Commercial Drivers License</option>

430
												<option>Certified Master Social Worker</option>

431
												<option>Certified Nursing Assistant</option>

432
												<option>Certified Professional Counselor</option>

433
												<option>Certified Registered Nurse Anesthetist</option>

434
												<option>Certified Social Worker</option>

435
												<option>Emergency Medical Technician</option>

436
												<option>Emergency Medical Technician-Intermediate</option>

437
												<option>Emergency Medical Technician-Paramedic</option>

438
												<option>First Responder</option>

439
												<option>Licensed Alcohol and Drug Counselor</option>

440
												<option>Licensed Child Care Provider</option>

441
												<option>Licensed Mental Health Practitioner</option>

442
												<option>Licensed Practical Nurse</option>

443
												<option>Lab Technician</option>

444
												<option>Medication Aid</option>

445
												<option>Medical Doctor</option>

446
												<option>Marriage and Family Therapist</option>

447
												<option>Nurse Aid</option>

448
												<option>NotChoose</option>

449
												<option>Nurse Practitioner</option>

450
												<option>Physician</option>

451
												<option>Physician Assistant</option>

452
												<option>Provisionally Certified Master Social Worker</option>

453
												<option>Pharmacist</option>

454
												<option>Provisional Licensed Alcohol & Drug Counselor</option>

455
												<option>Provisionally Licensed Mental Health Practitioner</option>

456
												<option>Psychiatrist</option>

457
												<option>Provisional Psychologist</option>

458
												<option>Psychologist Assistant</option>

459
												<option>Psychologist </option>

460
												<option>Registered Nurse</option>

461
												<option>Veterinarian</option>

462
												<option>Veterinarian Technician</option>

463
										</select></td>

464
						</tr>

465
						<tr>

466
								<td><label>Verification date</label></td>

467
								<td><input type="date" name="verf4" id="verf4" /></td>

468
								<td><label>License/Certificate #:</label></td>

469
								<td><input type="text" name="num4" id="num4" /></td>

470
								<td><label>Expiration date</label></td>

471
								<td><input type="date" name="exp4" id="exp4" /></td>

472
						</tr>

473
						<tr>

474
								<td colspan="2"><label>5-License/Certificate:</label></td>

475
								<td colspan="4"><select name="license5" id="license5">

476
												<option></option>

477
												<option>Advanced Practical Registered Nurse</option>

478
												<option>Commercial Drivers License</option>

479
												<option>Certified Master Social Worker</option>

480
												<option>Certified Nursing Assistant</option>

481
												<option>Certified Professional Counselor</option>

482
												<option>Certified Registered Nurse Anesthetist</option>

483
												<option>Certified Social Worker</option>

484
												<option>Emergency Medical Technician</option>

485
												<option>Emergency Medical Technician-Intermediate</option>

486
												<option>Emergency Medical Technician-Paramedic</option>

487
												<option>First Responder</option>

488
												<option>Licensed Alcohol and Drug Counselor</option>

489
												<option>Licensed Child Care Provider</option>

490
												<option>Licensed Mental Health Practitioner</option>

491
												<option>Licensed Practical Nurse</option>

492
												<option>Lab Technician</option>

493
												<option>Medication Aid</option>

494
												<option>Medical Doctor</option>

495
												<option>Marriage and Family Therapist</option>

496
												<option>Nurse Aid</option>

497
												<option>NotChoose</option>

498
												<option>Nurse Practitioner</option>

499
												<option>Physician</option>

500
												<option>Physician Assistant</option>

501
												<option>Provisionally Certified Master Social Worker</option>

502
												<option>Pharmacist</option>

503
												<option>Provisional Licensed Alcohol & Drug Counselor</option>

504
												<option>Provisionally Licensed Mental Health Practitioner</option>

505
												<option>Psychiatrist</option>

506
												<option>Provisional Psychologist</option>

507
												<option>Psychologist Assistant</option>

508
												<option>Psychologist </option>

509
												<option>Registered Nurse</option>

510
												<option>Veterinarian</option>

511
												<option>Veterinarian Technician</option>

512
										</select></td>

513
						</tr>

514
						<tr>

515
								<td><label>Verification date</label></td>

516
								<td><input type="date" name="verf5" id="verf5" /></td>

517
								<td><label>License/Certificate #:</label></td>

518
								<td><input type="text" name="num5" id="num5" /></td>

519
								<td><label>Expiration date</label></td>

520
								<td><input type="date" name="exp5" id="exp5" /></td>

521
						</tr>

522
				</table>

523
				<table style="width:850px; border:1px solid black;">

524
						<tr>

525
								<td><label>License Suspended/Revoked/Disciplined(Yes/No):</label></td>

526
								<td><select name="lsrd" id="lsrd">

527
												<option></option>

528
												<option>yes</option>

529
												<option>no</option>

530
										</select></td>

531
								<td><label>Specify if "Yes"</label></td>

532
								<td><input type="text" name="syes" id="syes" /></td>

533
						</tr>

534
						<tr>

535
								<td><label>Board Certified(Yes/No):</label></td>

536
								<td><select name="bcert" id="bcert">

537
												<option></option>

538
												<option>yes</option>

539
												<option>no</option>

540
										</select></td>

541
								<td><label>Prescriptive Authority(Yes/No):</label></td>

542
								<td><select name="pauth" id="pauth">

543
												<option></option>

544
												<option>yes</option>

545
												<option>no</option>

546
										</select></td>

547
						</tr>

548
				</table>

549
				<table style="width:850px; border:1px solid black;">

550
						<tr>

551
								<td colspan="4"><center>

552
												<label>EVC Roles</label>

553
										</center></td>

554
						</tr>

555
						<tr>

556
								<td><input type="checkbox" id="etrain" name="dataentry" value="Data Entry">

557
										<b>Data Entry</b></td>

558
								<td><input type="checkbox" id="etrain" name="identification" value="Identification Staff">

559
										<b>Identification staff</b></td>

560
								<td><input type="checkbox" id="etrain" name="phone" value="Phone Bank Staff">

561
										<b>Phone Bank Staff</b></td>

562
								<td><input type="checkbox" id="etrain" name="runner" value="Runner">

563
										<b>Runner</b></td>

564
						</tr>

565
						<tr>

566
								<td><input type="checkbox" id="etrain" name="greeter" value="Greeter">

567
										<b>Greeter</b></td>

568
								<td><input type="checkbox" id="etrain" name="interviewer" value="Interviewer">

569
										<b>Interviewer</b></td>

570
								<td colspan="2"><input type="checkbox" id="etrain" name="safety" value="Safety Orientation">

571
										<b>Safety Orientation</b></td>

572
						</tr>

573
				</table>

574
				<table style="width:850px; border: 1px solid black;">

575
						<tr>

576
								<td><label>1- Disaster Training</label></td>

577
								<td colspan="2"><select name="dist1">

578
												<option></option>

579
												<option>Advanced Disaster Life Support</option>

580
												<option>American Red Cross Disaster Mental Health</option>

581
												<option>Basic Disaster Life Support</option>

582
												<option>Community Emergency Response Team (CERT)</option>

583
												<option>Critical Incident Stress Management Advanced (CISM)</option>

584
												<option>Critical Incident Stress Management Basic</option>

585
												<option>Emergency  Volunteer Center (EVC)</option>

586
												<option>FEMA Crisis Counseling Grant</option>

587
												<option>NotChoose</option>

588
												<option>Nebraska Psychological First Aid</option>

589
												<option>National Incident Management System (NIMS)</option>

590
												<option>Other</option>

591
										</select></td>

592
								<td><label>Training Date</label></td>

593
								<td><input type="date" name="tdate1" /></td>

594
						</tr>

595
						<tr>

596
								<td><label>2- Disaster Training</label></td>

597
								<td colspan="2"><select name="dist2">

598
												<option></option>

599
												<option>Advanced Disaster Life Support</option>

600
												<option>American Red Cross Disaster Mental Health</option>

601
												<option>Basic Disaster Life Support</option>

602
												<option>Community Emergency Response Team (CERT)</option>

603
												<option>Critical Incident Stress Management Advanced (CISM)</option>

604
												<option>Critical Incident Stress Management Basic</option>

605
												<option>Emergency  Volunteer Center (EVC)</option>

606
												<option>FEMA Crisis Counseling Grant</option>

607
												<option>NotChoose</option>

608
												<option>Nebraska Psychological First Aid</option>

609
												<option>National Incident Management System (NIMS)</option>

610
												<option>Other</option>

611
										</select></td>

612
								<td><label>Training Date</label></td>

613
								<td><input type="date" name="tdate2" /></td>

614
						</tr>

615
						<tr>

616
								<td><label>3- Disaster Training</label></td>

617
								<td colspan="2"><select name="dist3">

618
												<option></option>

619
												<option>Advanced Disaster Life Support</option>

620
												<option>American Red Cross Disaster Mental Health</option>

621
												<option>Basic Disaster Life Support</option>

622
												<option>Community Emergency Response Team (CERT)</option>

623
												<option>Critical Incident Stress Management Advanced (CISM)</option>

624
												<option>Critical Incident Stress Management Basic</option>

625
												<option>Emergency  Volunteer Center (EVC)</option>

626
												<option>FEMA Crisis Counseling Grant</option>

627
												<option>NotChoose</option>

628
												<option>Nebraska Psychological First Aid</option>

629
												<option>National Incident Management System (NIMS)</option>

630
												<option>Other</option>

631
										</select></td>

632
								<td><label>Training Date</label></td>

633
								<td><input type="date" name="tdate3" /></td>

634
						</tr>

635
						<tr>

636
								<td><label>4- Disaster Training</label></td>

637
								<td colspan="2"><select name="dist4">

638
												<option></option>

639
												<option>Advanced Disaster Life Support</option>

640
												<option>American Red Cross Disaster Mental Health</option>

641
												<option>Basic Disaster Life Support</option>

642
												<option>Community Emergency Response Team (CERT)</option>

643
												<option>Critical Incident Stress Management Advanced (CISM)</option>

644
												<option>Critical Incident Stress Management Basic</option>

645
												<option>Emergency  Volunteer Center (EVC)</option>

646
												<option>FEMA Crisis Counseling Grant</option>

647
												<option>NotChoose</option>

648
												<option>Nebraska Psychological First Aid</option>

649
												<option>National Incident Management System (NIMS)</option>

650
												<option>Other</option>

651
										</select></td>

652
								<td><label>Training Date</label></td>

653
								<td><input type="date" name="tdate4" /></td>

654
						</tr>

655
						<tr>

656
								<td><label>5- Disaster Training</label></td>

657
								<td colspan="2"><select name="dist5">

658
												<option></option>

659
												<option>Advanced Disaster Life Support</option>

660
												<option>American Red Cross Disaster Mental Health</option>

661
												<option>Basic Disaster Life Support</option>

662
												<option>Community Emergency Response Team (CERT)</option>

663
												<option>Critical Incident Stress Management Advanced (CISM)</option>

664
												<option>Critical Incident Stress Management Basic</option>

665
												<option>Emergency  Volunteer Center (EVC)</option>

666
												<option>FEMA Crisis Counseling Grant</option>

667
												<option>NotChoose</option>

668
												<option>Nebraska Psychological First Aid</option>

669
												<option>National Incident Management System (NIMS)</option>

670
												<option>Other</option>

671
										</select></td>

672
								<td><label>Training Date</label></td>

673
								<td><input type="date" name="tdate5" /></td>

674
						</tr>

675
				</table>

676
				<table style="width:850px; border:solid black 1px;">

677
						<tr>

678
								<td><label>Convicted of a Felony (Not traffic violations) (Yes/No)</label></td>

679
								<td><select name="felony">

680
												<option></option>

681
												<option>Yes</option>

682
												<option>No</option>

683
										</select></td>

684
								<td><label>Specify if Yes</label></td>

685
								<td><input type="text" name="felonys" /></td>

686
						</tr>

687
				</table>

688
				<table style="width:850px; border:solid black 1px;">

689
						<tr>

690
								<td><label>Name:</label></td>

691
								<td colspan="2"><input type="text" name="ename" /></td>

692
								<td><label>Relationship:</label></td>

693
								<td colspan="2"><input type="text" name="erelation" style="width:300px;" /></td>

694
						</tr>

695
						<tr>

696
								<td><label>Home phone:</label></td>

697
								<td><input type="text" name="ehphone" /></td>

698
								<td><label>Mobile phone:</label></td>

699
								<td><input type="text" name="emphone" /></td>

700
								<td><label>Address:</label></td>

701
								<td><input type="text" name="eaddress" /></td>

702
						</tr>

703
						<tr>

704
								<td><label>City:</label></td>

705
								<td><input type="text" name="ecity" /></td>

706
								<td><label>State:</label></td>

707
								<td><input type="text" name="estate" /></td>

708
								<td><label>Zip:</label></td>

709
								<td><input type="text" name="ezip" /></td>

710
						</tr>

711
				</table>

712
				<table style="width:850px; border:solid black 1px;">

713
						<tr>

714
								<td><label>How Did you hear about us?</label></td>

715
								<td><select name="hdyhau">

716
												<option></option>

717
												<option>Friend</option>

718
												<option>County Fair</option>

719
												<option>Health fair</option>

720
												<option>Local Service Club</option>

721
												<option>Newspaper</option>

722
												<option>Website</option>

723
												<option>Other Community Event</option>

724
										</select></td>

725
						</tr>

726
						<tr>

727
								<td><label>Brief description and other info</label></td>

728
								<td><input type="text" name="bdesc" style="width:300px;" /></td>

729
						</tr>

730
				</table>

731
				<input type="submit" class="btn btn-primary" value="Submit" />

732
		</form>

733
		

734
</div>

735
<br>

736
<br>

737
<br>

738
</div>

739
</body>

740
</html>
        

    


            


                                


        

            



                
    

        Public Pastes
    

    
            

    

                    

        

    





    


    
    
    
    
    
    
    
    




    


    



                

            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!