<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN""http://www.w3.org/TR/html4/loose.dtd"><html><head><meta http-equiv="Content-Type" content="text/html; charset=ISO-8859-1"><title>Amity National Honor Society Online Sign Up System</title><style type="text/css"><!--.style1 {font-size: 11px}--></style></head><body><p align="center"><strong>AMITY CHAPTER OF THE NATIONAL HONOR SOCIETY</strong><br> <strong>Amity Regional High School</strong><br> <strong>25 Newton Road, Woodbridge, CT 06525</strong></p><p> </p><h3 align="center">Online Student Information Form</h3><p align="left"> </p><form name="form1" method="post" action=""> <p>Last Name - <input name="lastname" type="text" id="lastname" size="15"> First Name - <input name="firstname" type="text" id="firstname" size="25"> Middle Initial - <input name="mi" type="text" id="mi" size="5"></p> <p> </p> <p>Address - <input name="address" type="text" id="address" size="40"> </p> <p> </p> Town - <table width="200"> <tr> <td><label> <input type="radio" name="towns" value="bethany"> Bethany</label></td> </tr> <tr> <td><label> <input type="radio" name="towns" value="orange"> Orange</label></td> </tr> <tr> <td><label> <input type="radio" name="towns" value="woodbridge"> Woodbridge</label></td> </tr> </table> <p>Telephone - <input name="telnumber" type="text" id="telnumber" size="14"> </p> <p>Email - <input name="email" type="text" id="email" size="30"> </p> <p>Mailing Title for Parents or Guardiana (Mr. and Mrs. Frank Dixon, </p> <p>Dr. and Mrs. Frank Dixon, Ms. Mary Dixon, Mr. Frank Dixon) </p> <p> - <input name="mailtitle" type="text" id="mailtitle" size="30"> </p> <p>I attest that the information in my Student Information Activity Form is both true and accurate.</p> <p> <input name="atteststudent" type="checkbox" id="atteststudent" value="studentattest"> Date: <input name="textfield" type="text" size="10"> -- Student Name: <input name="textfield2" type="text" size="30"></p> <p> <input name="attestparent" type="checkbox" id="attestparent" value="parentattest"> Date: <input name="textfield3" type="text" size="10"> -- Parent/Guardian's Name: <input name="textfield4" type="text" size="30"></p> <p> </p> <p> </p> <p> <input type="submit" name="Submit" value="Submit"> </p> <p class="style1">Please do not press the submit button if the confirmation page does not appear immediately, if you do or if you get an error please refer to the link below to contact the technology office. </p> <p> </p></form><p>If you are experiencing problems with this system please contact the <a href="http://10.1.250.250/apps/syshelp">Technology Office. </a></p></body></html>