rendered paste body<?php require("./include/top.php");
header("Expires: Mon, 26 Jul 1997 05:00:00 GMT");
header("Cache-Control: no-cache");
header("Pragma: no-cache");
$to = 'pmsquillace@gmail.com';
$subject = 'Dance with CDA Registration Form';
$message = 'This is a registrant that filled out your form on your website';
$from = 'onlineregistration@dancewithcda.com';
$body = $_POST['Child_First_Name'];
$body = $_POST['Child_Last_Name'];
if (isset($submit)) {
mail($to,$subject,$message,$headers,$body);
}
?>
<style type="text/css">
img.aboutus
{
margin: 10px;
}
</style>
<h1>Got Bounce?</h1>
<h2>Dance and Cheer Clinic</h2>
<h3 class="plain">Join us for a week filled of dance, cheer, and FUN!! Let's kick off your summer '08 break with a BANG!.</h3>
<form name="got_bounce_form" action="<?php echo $_SERVER["PHP_SELF"];?>" method="post">
<table width="450" border="0" cellspacing="20" cellpadding="1" bgcolor="#cccccc">
<tr>
<td colspan="2" align="left" valign="top"><font face="Verdana, Arial, Helvetica, sans-serif" size="1"><b><u>Participant Information</u></b></font></td>
</tr>
<tr>
<td width="150" align="left" valign="top"><font face="Verdana, Arial, Helvetica, sans-serif" size="1">Child First Name: <font color="#FF0000">*</font><br>
<input name="Child_First_Name" type="text" id="Child_First_Name" size="20"></font><br></td>
<td colspan="2" align="left" valign="top"><font face="Verdana, Arial, Helvetica, sans-serif" size="1"><font face="Verdana, Arial, Helvetica, sans-serif" size="1">Child Last Name: <font color="#FF0000">*</font><br>
<input name="Child_Last_Name" type="text" id="Child_Last_Name" size="25"></font><br></td>
</tr>
<tr>
<td width="150" align="left" valign="top"><font face="Verdana, Arial, Helvetica, sans-serif" size="1"><font face="Verdana, Arial, Helvetica, sans-serif" size="1">Age: <br>
<input name="Child_Age" type="text" id="Child_Age" value="<?php if(isset($Child_Age) && ($Child_Age != '[NULL]')) { echo stripslashes($Child_Age);} else { if(!empty($_POST['Child_Age'])) { echo stripslashes($_POST['Child_Age']); } } ?>" size="10"></font><br /></td>
<td colspan="2" align="left" valign="top"><font face="Verdana, Arial, Helvetica, sans-serif" size="1">Any Medical Problems or Medications Student is on: <font color="#FF0000">*</font>
<input name="Child_Medical" type="text" id="Child_Medical" value="<?php if(isset($Child_Medical) && ($Child_Medical != '[NULL]')) { echo stripslashes($Child_Medical);} else { if(!empty($_POST['Child_Medical'])) { echo stripslashes($_POST['Child_Medical']); } } ?>" size="25"></font><br /></td>
</tr>
<tr>
<td colspan="2" align="left" valign="top"><font face="Verdana, Arial, Helvetica, sans-serif" size="1"><font face="Verdana, Arial, Helvetica, sans-serif" size="1">Experience: <font color="#FF0000">*</font>
<font face="Verdana, Arial, Helvetica, sans-serif" size="1"><br><input name="experience" type="radio" id="Experience_None" value="None">None<br><input name="experience" type="radio" id="Experience_Some" value="Some">Some<br><input name="experience" type="radio" id="Experience_ALot" value="A Lot">A Lot</font></td>
</tr>
<tr>
<td colspan="2" align="left" valign="middle"><font face="Verdana, Arial, Helvetica, sans-serif" size="1"><font face="Verdana, Arial, Helvetica, sans-serif" size="1">Size T-Shirt: <br><font color="#FF0000">*</font>
<font face="Verdana, Arial, Helvetica, sans-serif" size="1"><font face="Verdana, Arial, Helvetica, sans-serif" size="1"><input name="tshirtsize" type="radio" id="T_4_6" value="4-6" checked="checked">4-6<input name="tshirtsize" type="radio" id="T_8_10" value="8-10">8-10<input name="tshirtsize" type="radio" id="T_12_14" value="12-14">12-14<input name="tshirtsize" type="radio" id="T_Adult_Med" value="Adult Medium">Adult Med</font></td>
</tr>
<tr>
<td colspan="2" align="left" valign="top"><font face="Verdana, Arial, Helvetica, sans-serif" size="1"><b><u>Leagal Guardian Information</u></b></font></td>
</tr>
<tr>
<td width="150" align="left" valign="top"><font face="Verdana, Arial, Helvetica, sans-serif" size="1">First Name: <font color="#FF0000">*</font>
<input name="Adult_First_Name" type="text" id="Adult_First_Name" value="<?php if(isset($Adult_First_Name) && ($Adult_First_Name != '[NULL]')) { echo stripslashes($Adult_First_Name);} else { if(!empty($_POST['Adult_First_Name'])) { echo stripslashes($_POST['Adult_First_Name']); } } ?>" size="20"></font></td>
<td colspan="2" align="left" valign="top"><font face="Verdana, Arial, Helvetica, sans-serif" size="1"><font face="Verdana, Arial, Helvetica, sans-serif" size="1">Last Name: <font color="#FF0000">*</font>
<input name="Adult_Last_Name" type="text" id="Adult_Last_Name" value="<?php if(isset($Adult_Last_Name) && ($Adult_Last_Name != '[NULL]')) { echo stripslashes($Adult_Last_Name);} else { if(!empty($_POST['Adult_Last_Name'])) { echo stripslashes($_POST['Adult_Last_Name']); } } ?>" size="25"></font></td>
</tr>
<tr>
<td width="150" align="left" valign="top"><font face="Verdana, Arial, Helvetica, sans-serif" size="1">Address Line 1: <font color="#FF0000">*</font><br>
<input name="Address_Line_1" type="text" id="Address_Line_1" value="<?php if(isset($Address_Line_1) && ($Address_Line_1 != '[NULL]')) { echo stripslashes($Address_Line_1);} else { if(!empty($_POST['Address_Line_1'])) { echo stripslashes($_POST['Address_Line_1']); } } ?>" size="20"></font></td>
<td colspan="2" align="left" valign="top"><font face="Verdana, Arial, Helvetica, sans-serif" size="1"><font face="Verdana, Arial, Helvetica, sans-serif" size="1">Address Line 2: <font color="#FF0000">*</font>
<input name="Address_Line_2" type="text" id="Address_Line_2" value="<?php if(isset($Address_Line_2) && ($Address_Line_2 != '[NULL]')) { echo stripslashes($Address_Line_2);} else { if(!empty($_POST['Address_Line_2'])) { echo stripslashes($_POST['Address_Line_2']); } } ?>" size="25"></font></td>
</tr>
<tr>
<td width="150" align="left" valign="top"><font face="Verdana, Arial, Helvetica, sans-serif" size="1">City: <font color="#FF0000">*</font><br>
<input name="City" type="text" id="City" value="<?php if(isset($City) && ($City != '[NULL]')) { echo stripslashes($City);} else { if(!empty($_POST['City'])) { echo stripslashes($_POST['City']); } } ?>" size="20"></font></td>
<td width="50" align="left" valign="top"><font face="Verdana, Arial, Helvetica, sans-serif" size="1"><font face="Verdana, Arial, Helvetica, sans-serif" size="1">State: <font color="#FF0000">*</font><br>
<input name="State" type="text" id="State" value="<?php if(isset($State) && ($State != '[NULL]')) { echo stripslashes($State);} else { if(!empty($_POST['State'])) { echo stripslashes($_POST['State']); } } ?>" size="3"></font>
<td width="50" align="left" valign="top"><font face="Verdana, Arial, Helvetica, sans-serif" size="1"><font face="Verdana, Arial, Helvetica, sans-serif" size="1">Zip Code: <font color="#FF0000">*</font><br>
<input name="Postal_Code" type="text" id="Postal_Code" value="<?php if(isset($Postal_Code) && ($Postal_Code != '[NULL]')) { echo stripslashes($Postal_Code);} else { if(!empty($_POST['Postal_Code'])) { echo stripslashes($_POST['Postal_Code']); } } ?>" size="10"></font><br></td>
</tr>
<tr>
<td colspan="2" align="left" valign="top"><font face="Verdana, Arial, Helvetica, sans-serif" size="1"><b><u>Choice of Payment/Cost is $60.00 Per Student</u></b></font></td>
</tr>
<tr>
<td colspan="3" align="left" valign="middle"><font face="Verdana, Arial, Helvetica, sans-serif" size="1"><font color="#000000" font face="Verdana, Arial, Helvetica, sans-serif" size="1"><input name="payments" type="radio" id="PayPal" value="selected">PayPal on CDA Website<input name="payments" type="radio" id="Check" value="None">Check</font></td>
</tr>
<tr>
<td colspan="3" align="left" valign="top"><font face="Verdana, Arial, Helvetica, sans-serif" size="1">Emaill Address: <font color="#FF0000">*</font><br>
<input name="email" type="text" id="email" value="<?php if(isset($email) && ($email != '[NULL]')) { echo stripslashes($email);} else { if(!empty($_POST['email'])) { echo stripslashes($_POST['email']); } } ?>" size="50"></font></td>
</tr>
<tr>
<td colspan="3" align="left" valign="top"><font face="Verdana, Arial, Helvetica, sans-serif" size="1"><b><u>Liability Waiver</u></b><br><br>By sending my child to this dance/cheer clinic, I understand that dancing and cheer related activities present a risk of injury to the participant. I understand that there is an inherent risk of injury that cannot be eliminated regardless of the care taken to avoid injury. I agree to assume the risk in order for my child to participate in these activities. I do hearby release and forever discharge CDA LLC and their instructors from all claims, expenses, attorney fees, and causes of action or suits of any kind of nature associated with my child involvment with CDA LLC.</font></td>
</tr>
<tr>
<td colspan="3" align="left" valign="top"><input name="submit" type="submit" id="submit" value="Sign Up" /></td>
</tr>
</table>
</form>
<?php require("./include/bottom.php"); ?>