All pastes #404087 Raw Edit

Unnamed

public text v1 · immutable
·published 2007-03-20 20:24 UTC
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<p align="center"><span class="style1"><strong>INSCHRIJVING</strong></span></p>
<p align="center" class="style1"><strong>MASTERCLASS / CLINIC</strong></p>
<form name="inschrijvingen" method="post" action="mail.php">
  <table width="430" border="0" cellspacing="0" cellpadding="0">
    <tr>
      <td width="168"><span class="style1">Naam:</span></td>
      <td width="300"><span class="style1">
        <input name="naam" type="text" size="40" />
      </span></td>
    </tr>
    <tr>
      <td><span class="style1">E-mail:</span></td>
      <td><span class="style1">
        <input name="mail" type="text" size="40" />
      </span></td>
    </tr>
    <tr>
      <td><span class="style1">Tel (of GSM): </span></td>
      <td><span class="style1">
        <input name="tel" type="text" size="40" />
      </span></td>
    </tr>
    <tr>
      <td><span class="style1">Muziekschool of conservatorium   waar les wordt gevolgd (of is gevolgd)&nbsp;</span></td>
      <td>
        <textarea name="school" cols="38"></textarea>
</td>
    </tr>
    <tr>
      <td><span class="style1">Wenst in te schrijven voor de masterclass/clinic</span></td>
      <td><span class="style1">
        
          <input type="checkbox" name="checkbox1" value="klarinet_Eddy" />
          Klarinet / Eddy Vanoosthuyse<br />
          <input type="checkbox" name="checkbox2" value="Basklarinet_Marc" />
          Basklarinet / Marc Kerckhof<br />
          <input type="checkbox" name="checkbox3" value="Es_klarinet_David" />
          Es klarinet / David Van Maele <br />
          <input type="checkbox" name="checkbox4" value="Jazz_Michel" />
          Jazz / Michel Pelligrino<br />
          <input type="checkbox" name="checkbox5" value="Klezmer_Peter" />
          Klezmer / Peter Merckx<br />
          <input type="checkbox" name="checkbox6" value="Oude_klarinet_Vincenzo" />
          Oude klarinet / Vincenzo Casale 
      </span></td>
    </tr>
    <tr>
      <td><span class="style1">In geval van masterclass basklarinet of es klarinet</span></td>
      <td><table width="238">
          <tr>
            <td width="230" class="style1"><label>
              <input type="radio" name="Klarinet" value="wel_een_klarinet" />
              Ik beschik over een klarinet</label></td>
          </tr>
          <tr>
            <td class="style1"><label>
              <input type="radio" name="Klarinet" value="geen_klarinet" />
              Ik beschik niet over een klarinet</label></td>
          </tr>
      </table></td>
    </tr>
  </table>
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    <input type="submit" name="Submit" value="Versturen" />
  </p>
</form>
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