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| 09.24.2008 at 07:25PM PDT, ID: 23761138 |
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join_lifeplanner.asp:
<%
if request.form("action") = "Submit" then
%><!-- #include file = "registration_save_inc.asp" --><%
end if
%>
<!-- #include file = "header_inc.asp" -->
<!-- #include file = "menu_inc.asp" -->
<div id="content">
<h2>Join The Directory</h2>
<p>Please fill out the form to be added the Directory. </p>
</div>
<div id="regform"><form name="regform" method="post" action="join_lifeplanner.asp?">
<!-- #include file = "directory_form_inc.asp" -->
</form>
</div>
<!-- #include file = "footer_inc.asp" -->
<%
function quotestring(s, endchar)
s = replace(trim(s),"'","''")
quotestring = "'" & s & "'" & endchar
end function
if (firstname = "" or lastname = "" or company = "" or primaryphone = "" or email = "" or street1 = "" or city1 = "" or state1 = "" or zip1 = "" or country1 = "" or phone1 = "" or chbdegrees = "" or chbcertifications = "" or practice = "" or chbpediatric = "" or chbadult ="" or verify="") and request("action") = "Submit" then
%><script>alert('You did not fill a required field. All fields marked * are required.')</script><%
end if
%>
registration_save_inc.asp:
<%
prefix = request("prefix")
firstname = request("firstname")
middleinit = request("middleinit")
lastname = request("lastname")
suffix = request("suffix")
company = request("company")
region = request("region")
primaryphone = request("primaryphone")
email = request("email")
website = request("website")
street1 = request("street1")
city1 = request("city1")
state1 = request("state1")
zip1 = request("zip1")
country1 = request("country1")
phone1 = request("phone1")
fax1 = request("fax1")
street2 = request("street2")
city2 = request("city2")
state2 = request("state2")
zip2 = request("zip2")
country2 = request("country2")
phone2 = request("phone2")
fax2 = request("fax2")
chbdegrees = request("chbdegrees")
chbcertifications = request("chbcertifications")
practice = request("practice")
chbpediatric = request("chbpediatric")
chbadult = request("chbadult")
info = request("info")
verify = request("verify")
if request("sign_up") = "YES" then
sign_up = true
else
sign_up = false
end if
if (cstr(request("verify")) <> cstr(session("check_str")) and session("check_str") <> "") then
verify = ""
end if
if firstname = "" or lastname = "" or company = "" or primaryphone = "" or email = "" or street1 = "" or city1 = "" or state1 = "" or zip1 = "" or country1 = "" or phone1 = "" or chbdegrees = "" or chbcertifications = "" or practice = "" or chbpediatric = "" or chbadult ="" or verify="" then
else
Set conn = Server.CreateObject("ADODB.Connection")
conn.Open session("conn_CarePlanners_db")
sql = "delete * from directory where firstname = " & quotestring(firstname,"") & " and lastname = " & quotestring(lastname,"")
conn.execute(sql)
sql = " insert into directory ("
sql = sql & "prefix,"
sql = sql & "firstname,"
sql = sql & "middleinit,"
sql = sql & "lastname,"
sql = sql & "suffix,"
sql = sql & "company,"
sql = sql & "region,"
sql = sql & "primaryphone,"
sql = sql & "email,"
sql = sql & "website,"
sql = sql & "street1,"
sql = sql & "city1,"
sql = sql & "state1,"
sql = sql & "zip1,"
sql = sql & "country1,"
sql = sql & "phone1,"
sql = sql & "fax1,"
sql = sql & "street2,"
sql = sql & "city2,"
sql = sql & "state2,"
sql = sql & "zip2,"
sql = sql & "country2,"
sql = sql & "phone2,"
sql = sql & "fax2,"
sql = sql & "chbdegrees,"
sql = sql & "chbcertifications,"
sql = sql & "practice,"
sql = sql & "chbpediatric,"
sql = sql & "chbadult,"
sql = sql & "sign_up,"
sql = sql & "info"
sql = sql & ")values("
sql = sql & quotestring(prefix,",")
sql = sql & quotestring(firstname,",")
sql = sql & quotestring(middleinit,",")
sql = sql & quotestring(lastname,",")
sql = sql & quotestring(suffix,",")
sql = sql & quotestring(company,",")
sql = sql & quotestring(region,",")
sql = sql & quotestring(primaryphone,",")
sql = sql & quotestring(email,",")
sql = sql & quotestring(website,",")
sql = sql & quotestring(street1,",")
sql = sql & quotestring(city1,",")
sql = sql & quotestring(state1,",")
sql = sql & quotestring(zip1,",")
sql = sql & quotestring(country1,",")
sql = sql & quotestring(phone1,",")
sql = sql & quotestring(fax1,",")
sql = sql & quotestring(street2,",")
sql = sql & quotestring(city2,",")
sql = sql & quotestring(state2,",")
sql = sql & quotestring(zip2,",")
sql = sql & quotestring(country2,",")
sql = sql & quotestring(phone2,",")
sql = sql & quotestring(fax2,",")
sql = sql & quotestring(chbdegrees,",")
sql = sql & quotestring(chbcertifications,",")
sql = sql & quotestring(practice,",")
sql = sql & quotestring(chbpediatric,",")
sql = sql & quotestring(chbadult,",")
sql = sql & sign_up & ","
sql = sql & quotestring(info,"")
sql = sql & ")"
conn.execute(sql)
conn.close
set conn = nothing
BodyText = "There was a new submission for Care Planners Directory" & vbcrlf & "Please visit site maintenance to review it at "&application("website")&"maint/" & vbcrlf
Set Objmail=Server.CreateObject("CDONTS.NewMail")
Objmail.From = application("notification_email")
Objmail.To = application("notification_email")
Objmail.Subject = "** New listing in Care Planners Directory"
Objmail.Body = BodyText
Objmail.Send
Set Objmail = nothing
if sign_up and email<>"" then
Set myMail=CreateObject("CDO.Message")
myMail.From = mailfrom
myMail.To = "STServ@careplanners.net"
myMail.Subject = ""
myMail.TextBody = "subscribe lcpforum"
myMail.Configuration.Fields.Item("http://schemas.microsoft.com/cdo/configuration/sendusing")=2
myMail.Configuration.Fields.Item("http://schemas.microsoft.com/cdo/configuration/smtpserver") = "mail.careplanners.net"
myMail.Configuration.Fields.Item("http://schemas.microsoft.com/cdo/configuration/smtpserverport") = 25
myMail.Configuration.Fields.Update
mymail.Configuration.Fields.Item ("http://schemas.microsoft.com/cdo/configuration/smtpauthenticate") = 1 'basic (clear-text) authentication
mymail.Configuration.Fields.Item ("http://schemas.microsoft.com/cdo/configuration/sendusername") ="sgrisham"
mymail.Configuration.Fields.Item ("http://schemas.microsoft.com/cdo/configuration/sendpassword") ="susan5"
myMail.Send
Set myMail = Nothing
end if
response.redirect "thankyou.asp"
response.end
end if
function quotestring (s, endchar)
quotestring = "'" & replace(cstr(s),"'","''") & "'" & endchar
end function
%>
directory_form_inc.asp:
<table cellSpacing="0" cellPadding="2" border=0>
<tr>
<td colSpan="4"><h3>Business Information:</h3></td>
</tr>
<tr>
<td align="right">Prefix:</td>
<td><select id="select" name="prefix">
<option <% if prefix = "Mr." then %>selected<%end if%>>Mr.</option>
<option <% if prefix = "Mrs." then %>selected<%end if%>>Mrs.</option>
<option <% if prefix = "Miss." then %>selected<%end if%>>Miss.</option>
<option <% if prefix = "Ms." then %>selected<%end if%>>Ms.</option>
<option <% if prefix = "Dr." then %>selected<%end if%>>Dr.</option>
<option <% if prefix = "" then %>selected<%end if%>></option>
</select>
</td>
<td align="right"><font color="red">* </font>First Name:</td>
<td><INPUT id="firstname" type="text" maxLength="40" name="firstname" value="<%=firstname%>"></td>
</tr>
<tr>
<td align="right">Middle Initial:</td>
<td><INPUT id="middleinit" type="text" maxLength="10" size="5" name="middleinit" value="<%=middleinit%>"></td>
<td align="right"><font color="red">* </font>Last Name:</td>
<td><INPUT id="lastname" type="text" maxLength="40" name="lastname" value="<%=lastname%>"></td>
</tr>
<tr>
<td align="right">Suffix:</td>
<td><select id="suffix" name="suffix">
<option <%if suffix = "-" then%>selected<%end if%>>-</option>
<option <%if suffix = "Jr." then%>selected<%end if%>>Jr.</option>
<option <%if suffix = "Sr." then%>selected<%end if%>>Sr.</option>
<option <%if suffix = "II" then%>selected<%end if%>>II</option>
<option <%if suffix = "III" then%>selected<%end if%>>III</option>
</select>
</td>
</tr>
<tr>
<td align="right" width="50"><font color="red">* </font>Organization / Business Name:</td>
<td colSpan="3"><INPUT id="company" type="text" maxLength="80" size="50" name="company" value="<%=company%>"></td>
</tr>
<tr>
<td align="right" width="50">Geographic regions served:</td>
<td><SELECT id="region" name="region">
<OPTION selected value="">---------------------------------</OPTION>
<OPTION <%if region="All U.S" then%>selected<%end if%>>All U.S</OPTION>
<OPTION <%if region="Alabama" then%>selected<%end if%>>Alabama</OPTION>
<OPTION <%if region="Alaska" then%>selected<%end if%>>Alaska</OPTION>
<OPTION <%if region="Arizona" then%>selected<%end if%>>Arizona</OPTION>
<OPTION <%if region="Arkansas" then%>selected<%end if%>>Arkansas</OPTION>
<OPTION <%if region="California" then%>selected<%end if%>>California</OPTION>
<OPTION <%if region="Colorado" then%>selected<%end if%>>Colorado</OPTION>
<OPTION <%if region="Connecticut" then%>selected<%end if%>>Connecticut</OPTION>
<OPTION <%if region="Delaware" then%>selected<%end if%>>Delaware</OPTION>
<OPTION <%if region="Florida" then%>selected<%end if%>>Florida</OPTION>
<OPTION <%if region="Georgia" then%>selected<%end if%>>Georgia</OPTION>
<OPTION <%if region="Hawaii" then%>selected<%end if%>>Hawaii</OPTION>
<OPTION <%if region="Idaho" then%>selected<%end if%>>Idaho</OPTION>
<OPTION <%if region="Illinois" then%>selected<%end if%>>Illinois</OPTION>
<OPTION <%if region="Indiana" then%>selected<%end if%>>Indiana</OPTION>
<OPTION <%if region="Iowa" then%>selected<%end if%>>Iowa</OPTION>
<OPTION <%if region="Kansas" then%>selected<%end if%>>Kansas</OPTION>
<OPTION <%if region="Kentucky" then%>selected<%end if%>>Kentucky</OPTION>
<OPTION <%if region="Louisiana" then%>selected<%end if%>>Louisiana</OPTION>
<OPTION <%if region="Maine" then%>selected<%end if%>>Maine</OPTION>
<OPTION <%if region="Maryland" then%>selected<%end if%>>Maryland</OPTION>
<OPTION <%if region="Massachusetts" then%>selected<%end if%>>Massachusetts</OPTION>
<OPTION <%if region="Michigan" then%>selected<%end if%>>Michigan</OPTION>
<OPTION <%if region="Minnesota" then%>selected<%end if%>>Minnesota</OPTION>
<OPTION <%if region="Mississippi" then%>selected<%end if%>>Mississippi</OPTION>
<OPTION <%if region="Missouri" then%>selected<%end if%>>Missouri</OPTION>
<OPTION <%if region="Montana" then%>selected<%end if%>>Montana</OPTION>
<OPTION <%if region="Nebraska" then%>selected<%end if%>>Nebraska</OPTION>
<OPTION <%if region="Nevada" then%>selected<%end if%>>Nevada</OPTION>
<OPTION <%if region="New Hampshire" then%>selected<%end if%>>New Hampshire</OPTION>
<OPTION <%if region="New Jeresy" then%>selected<%end if%>>New Jeresy</OPTION>
<OPTION <%if region="New Mexico" then%>selected<%end if%>>New Mexico</OPTION>
<OPTION <%if region="New York" then%>selected<%end if%>>New York</OPTION>
<OPTION <%if region="North Carolina" then%>selected<%end if%>>North Carolina</OPTION>
<OPTION <%if region="North Dakota" then%>selected<%end if%>>North Dakota</OPTION>
<OPTION <%if region="Ohio" then%>selected<%end if%>>Ohio</OPTION>
<OPTION <%if region="Oklahoma" then%>selected<%end if%>>Oklahoma</OPTION>
<OPTION <%if region="Oregon" then%>selected<%end if%>>Oregon</OPTION>
<OPTION <%if region="Pennsylvania" then%>selected<%end if%>>Pennsylvania</OPTION>
<OPTION <%if region="Rhode Island" then%>selected<%end if%>>Rhode Island</OPTION>
<OPTION <%if region="South Carolina" then%>selected<%end if%>>South Carolina</OPTION>
<OPTION <%if region="South Dakota" then%>selected<%end if%>>South Dakota</OPTION>
<OPTION <%if region="Tennessee" then%>selected<%end if%>>Tennessee</OPTION>
<OPTION <%if region="Texas" then%>selected<%end if%>>Texas</OPTION>
<OPTION <%if region="Utah" then%>selected<%end if%>>Utah</OPTION>
<OPTION <%if region="Vermont" then%>selected<%end if%>>Vermont<OPTION>
<OPTION <%if region="Virginia" then%>selected<%end if%>>Virginia<OPTION>
<OPTION <%if region="Washington" then%>selected<%end if%>>Washington<OPTION>
<OPTION <%if region="Washington D.C." then%>selected<%end if%>>Washington D.C.<OPTION>
<OPTION <%if region="West Virginia" then%>selected<%end if%>>West Virginia<OPTION>
<OPTION <%if region="Wisconsin" then%>selected<%end if%>>Wisconsin<OPTION>
<OPTION <%if region="Wyoming" then%>selected<%end if%>>Wyoming<OPTION>
<OPTION <%if region="Canada" then%>selected<%end if%>>Canada</OPTION>
<OPTION <%if region="Argentina" then%>selected<%end if%>>Argentina</OPTION>
<OPTION <%if region="Australia" then%>selected<%end if%>>Australia</OPTION>
<OPTION <%if region="Austria" then%>selected<%end if%>>Austria</OPTION>
<OPTION <%if region="Brazil" then%>selected<%end if%>>Brazil</OPTION>
<OPTION <%if region="China" then%>selected<%end if%>>China</OPTION>
<OPTION <%if region="Colombia" then%>selected<%end if%>>Colombia</OPTION>
<OPTION <%if region="Costa Rica" then%>selected<%end if%>>Costa Rica</OPTION>
<OPTION <%if region="Czech Republic" then%>selected<%end if%>>Czech Republic</OPTION>
<OPTION <%if region="Denmark" then%>selected<%end if%>>Denmark</OPTION>
<OPTION <%if region="Egypt" then%>selected<%end if%>>Egypt</OPTION>
<OPTION <%if region="France" then%>selected<%end if%>>France</OPTION>
<OPTION <%if region="Germany" then%>selected<%end if%>>Germany</OPTION>
<OPTION <%if region="Hong Kong" then%>selected<%end if%>>Hong Kong</OPTION>
<OPTION <%if region="India" then%>selected<%end if%>>India</OPTION>
<OPTION <%if region="Indonesia" then%>selected<%end if%>>Indonesia</OPTION>
<OPTION <%if region="Ireland" then%>selected<%end if%>>Ireland</OPTION>
<OPTION <%if region="Israel" then%>selected<%end if%>>Israel</OPTION>
<OPTION <%if region="Italy" then%>selected<%end if%>>Italy</OPTION>
<OPTION <%if region="Japan" then%>selected<%end if%>>Japan</OPTION>
<OPTION <%if region="Korea" then%>selected<%end if%>>Korea</OPTION>
<OPTION <%if region="Malaysia" then%>selected<%end if%>>Malaysia</OPTION>
<OPTION <%if region="Mexico" then%>selected<%end if%>>Mexico</OPTION>
<OPTION <%if region="Netherlands" then%>selected<%end if%>>Netherlands</OPTION>
<OPTION <%if region="New Zealand" then%>selected<%end if%>>New Zealand</OPTION>
<OPTION <%if region="Philippines" then%>selected<%end if%>>Philippines</OPTION>
<OPTION <%if region="Poland" then%>selected<%end if%>>Poland</OPTION>
<OPTION <%if region="Russia" then%>selected<%end if%>>Russia</OPTION>
<OPTION <%if region="Singapore" then%>selected<%end if%>>Singapore</OPTION>
<OPTION <%if region="South Africa" then%>selected<%end if%>>South Africa</OPTION>
<OPTION <%if region="Spain" then%>selected<%end if%>>Spain</OPTION>
<OPTION <%if region="Sweden" then%>selected<%end if%>>Sweden</OPTION>
<OPTION <%if region="Taiwan" then%>selected<%end if%>>Taiwan</OPTION>
<OPTION <%if region="Thailand" then%>selected<%end if%>>Thailand</OPTION>
<OPTION <%if region="Turkey" then%>selected<%end if%>>Turkey</OPTION>
<OPTION <%if region="UAE" then%>selected<%end if%>>UAE</OPTION>
<OPTION <%if region="UK" then%>selected<%end if%>>UK</OPTION>
<OPTION <%if region="Ukraine" then%>selected<%end if%>>Ukraine</OPTION>
<OPTION <%if region="Vietnam" then%>selected<%end if%>>Vietnam</OPTION>
</SELECT>
</td>
<td align="right"><font color="red">* </font>Primary Contact Phone:</td>
<td><INPUT id="primaryphone" type="text" maxLength="20" name="primaryphone" value="<%=primaryphone%>"></td>
<td width="0"></td>
</tr>
<tr>
<td align="right" style="white-space:nowrap; "><font color="red">* </font>Email Address:</td>
<td><INPUT id="email" type="text" maxLength="50" name="email" value="<%=email%>"></td>
<td align=right>Website Address:</td>
<td><INPUT id="website" type="text" maxLength="80" name="website" value="<%=website%>"></td>
</tr>
<tr>
<td></td>
<td colspan=4><INPUT id="sign_up" type="checkbox" maxLength="50" name="sign_up" <%if sign_up then %>checked<%end if%> value="YES">Sign Up to Care Planner Network mailing list.</td>
</tr>
<tr>
<td colSpan="4"><h3>Business Address 1:</h3></td>
</tr>
<tr>
<td align=right><font color="red">* </font>Street:</td>
<td colSpan="3"><INPUT id="street1" type="text" maxLength="80" size="50" name="street1" value="<%=street1%>"></td>
</tr>
<tr>
<td align=right><font color="red">* </font>City:</td>
<td><INPUT id="city1" type="text" maxLength="40" name="city1" value="<%=city1%>"></td>
<td align=right><font color="red">* </font>State:</td>
<td>
<select name="state1" id="state1">
<% selected_state = state1 %>
<!-- #include file = "state_list_inc.asp" -->
</select>
</td>
</tr>
<tr>
<td align="right"><font color="red">* </font>Zip:</td>
<td><INPUT id="zip1" type="text" maxLength="10" name="zip1" value="<%=zip1%>"></td>
<td align="right"><font color="red">* </font>Country:</td>
<td><INPUT id="country1" type="text" maxLength="40" name="country1" value="<%=country1%>"></td>
</tr>
<tr>
<td align="right"><font color="red">* </font>Telephone:</td>
<td><INPUT id="phone1" type="text" maxLength="20" name="phone1" value="<%=phone1%>"></td>
<td align="right">Fax:</td>
<td><INPUT id="fax1" type="text" maxLength="20" name="fax1" value="<%=fax1%>"></td>
</tr>
<tr>
<td colSpan="4"><h3>Business Address 2:</h3></td>
</tr>
<tr>
<td align="right">Street:</td>
<td colSpan="3"><INPUT id="street2" type="text" maxLength="80" size="50" name="street2" value="<%=street2%>"></td>
</tr>
<tr>
<td align="right">City:</td>
<td><INPUT id="city2" type="text" name="city2" value="<%=city2%>"></td>
<td align="right">State:</td>
<td>
<select name="state2" id="state2">
<% selected_state = state2 %>
<!-- #include file = "state_list_inc.asp" -->
</select>
</td>
</tr>
<tr>
<td align="right">Zip:</td>
<td><INPUT id="zip2" type="text" name="zip2" value="<%=zip2%>"></td>
<td align="right">Country:</td>
<td><INPUT id="country2" type="text" name="country2" value="<%=country2%>"></td>
</tr>
<tr>
<td align="right">Telephone:</td>
<td><INPUT id="phone2" type="text" name="phone2" value="<%=phone2%>"></td>
<td align="right">Fax:</td>
<td><INPUT id="fax2" type="text" name="fax2" value="<%=fax2%>"></td>
</tr>
<tr>
<td colSpan="4"><h3><font color="red">* </font>Degrees Earned:</h3></td>
</tr>
<tr>
<td colSpan="4">
<table cellpadding="2" border=0 width="600">
<tr>
<td style="white-space:nowrap "><INPUT name="chbdegrees" type="checkbox" value="Diploma Nursing" <%=check_check("chbdegrees","Diploma Nursing")%>>Diploma Nursing</td>
<td><INPUT name="chbdegrees" type="checkbox" value="BSN" <%=check_check("chbdegrees","BSN")%>>BSN</td>
<td><INPUT name="chbdegrees" type="checkbox" value="MSN" <%=check_check("chbdegrees","MSN")%>>MSN</td>
<td><INPUT name="chbdegrees" type="checkbox" value="MD" <%=check_check("chbdegrees","MD")%>>MD</td>
</tr>
<tr>
<td><INPUT name="chbdegrees" type="checkbox" value="BA" <%=check_check("chbdegrees","BA")%>>BA</td>
<td><INPUT name="chbdegrees" type="checkbox" value="MA" <%=check_check("chbdegrees","MA")%>>MA</td>
<td><INPUT name="chbdegrees" type="checkbox" value="BS" <%=check_check("chbdegrees","BS")%>>BS</td>
<td><INPUT name="chbdegrees" type="checkbox" value="Ph.D" <%=check_check("chbdegrees","Ph.D")%>>Ph.D</td>
</tr>
<tr>
<td><INPUT name="chbdegrees" type="checkbox" value="MEd" <%=check_check("chbdegrees","MEd")%>>MEd</td>
<td><INPUT name="chbdegrees" type="checkbox" value="EdD" <%=check_check("chbdegrees","EdD")%>>EdD</td>
<td><INPUT name="chbdegrees" type="checkbox" value="MS" <%=check_check("chbdegrees","MS")%>>MS</td>
<td><INPUT name="chbdegrees" type="checkbox" value="Other" <%=check_check("chbdegrees","Other")%>>Other</td>
</tr>
<tr>
<td colSpan="4"><h3><font color="red">* </font>Certifications:</h3>
</tr>
<tr>
<td><INPUT name="chbcertifications" type="checkbox" value="ABPP" <%=check_check("chbcertifications","ABPP")%>>ABPP</td>
<td><INPUT name="chbcertifications" type="checkbox" value="ACSW" <%=check_check("chbcertifications","ACSW")%>>ACSW</td>
<td><INPUT name="chbcertifications" type="checkbox" value="CCM" <%=check_check("chbcertifications","CCM")%>>CCM</td>
<td><INPUT name="chbcertifications" type="checkbox" value="CLCP" <%=check_check("chbcertifications","CLCP")%>>CLCP</td>
</tr>
<tr>
<td><INPUT name="chbcertifications" type="checkbox" value="CRC" <%=check_check("chbcertifications","CRC")%>>CRC</td>
<td><INPUT name="chbcertifications" type="checkbox" value="CVE" <%=check_check("chbcertifications","CVE")%>>CVE</td>
<td><INPUT name="chbcertifications" type="checkbox" value="NCC" <%=check_check("chbcertifications","NCC")%>>NCC</td>
<td><INPUT name="chbcertifications" type="checkbox" value="ABVE" <%=check_check("chbcertifications","ABVE")%>>ABVE</td>
</tr>
<tr>
<td><INPUT name="chbcertifications" type="checkbox" value="CCC-SLP" <%=check_check("chbcertifications","CCC-SLP")%>>CCC-SLP</td>
<td><INPUT name="chbcertifications" type="checkbox" value="CDMS" <%=check_check("chbcertifications","CDMS")%>>CDMS</td>
<td><INPUT name="chbcertifications" type="checkbox" value="CNLCP" <%=check_check("chbcertifications","CNLCP")%>>CNLCP</td>
<td><INPUT name="chbcertifications" type="checkbox" value="CRRN" <%=check_check("chbcertifications","CRRN")%>>CRRN</td>
</tr>
<tr>
<td><INPUT name="chbcertifications" type="checkbox" value="LNCC" <%=check_check("chbcertifications","LNCC")%>>LNCC</td>
<td><INPUT name="chbcertifications" type="checkbox" value="MSCC" <%=check_check("chbcertifications","MSCC")%>>MSCC</td>
<td><INPUT name="chbcertifications" type="checkbox" value="OTHER" <%=check_check("chbcertifications","OTHER")%>>OTHER</td>
</tr>
<tr><td colSpan="4"><h3><font color="red">* </font>Primary Field of Practice:</h3></td></tr>
<tr>
<td><input name="practice" type="radio" value="Attorney" <%=check_check("practice","Attorney")%>>Attorney</td>
<td><INPUT name="practice" type="radio" value="Nursing" <%=check_check("practice","Nursing")%>>Nursing</td>
<td><INPUT name="practice" type="radio" value="Physical Therapy" <%=check_check("practice","Physical Therapy")%>>Physical Therapy</td>
<td><INPUT name="practice" type="radio" value="Social Work" <%=check_check("practice","Social Work")%>>Social Work</td>
</tr>
<tr>
<td><INPUT name="practice" type="radio" value="Counselling" <%=check_check("practice","Counseling")%>>Counseling</td>
<td><INPUT name="practice" type="radio" value="Occupational Therapy" <%=check_check("practice","Occupational Therapy")%>>Occupational Therapy</td>
<td><INPUT name="practice" type="radio" value="Psychology" <%=check_check("practice","Psychology")%>>Psychology</td>
<td><INPUT name="practice" type="radio" value="Medicine" <%=check_check("practice","Medicine")%>>Medicine</td>
</tr>
<tr>
<td><INPUT name="practice" type="radio" value="Speech Therapy" <%=check_check("practice","Speech Therapy")%>>Speech Therapy</td>
<td><INPUT name="practice" type="radio" value="Rehabilitation Counselling"<%=check_check("practice","Rehabilitation Counselling")%>>Rehabilitation Counseling</td>
<td><INPUT name="practice" type="radio" value="Other" <%=check_check("practice","Other")%>>Other</td>
</tr>
<tr><td colSpan="4"><br />
<h3>Life Care Planning/Case Management Speciality Area(s):</h3><br /><br />
<h3><font color="red">* </font>Pediatric</h3>
</td></tr>
<tr>
<td><INPUT name="chbpediatric" type="checkbox" value="Spinal Cord Injury" <%=check_check("chbpediatric","Spinal Cord Injury")%>>Spinal Cord Injury</td>
<td><INPUT name="chbpediatric" type="checkbox" value="Birth Injury" <%=check_check("chbpediatric","Birth Injury")%>>Birth Injury</td>
<td><INPUT name="chbpediatric" type="checkbox" value="Psychiatric" <%=check_check("chbpediatric","Psychiatric")%>>Psychiatric</td>
<td><INPUT name="chbpediatric" type="checkbox" value="Chronic Pain" <%=check_check("chbpediatric","Chronic Pain")%>>Chronic Pain</td>
</tr>
<tr>
<td><INPUT name="chbpediatric" type="checkbox" value="Burns" <%=check_check("chbpediatric","Burns")%>>Burns</td>
<td><INPUT name="chbpediatric" type="checkbox" value="Acquired Brain Injury" <%=check_check("chbpediatric","Acquired Brain Injury")%>>Acquired Brain Injury</td>
<td><INPUT name="chbpediatric" type="checkbox" value="Multiple Trauma" <%=check_check("chbpediatric","Multiple Trauma")%>>Multiple Trauma</td>
<td><INPUT name="chbpediatric" type="checkbox" value="All" <%=check_check("chbpediatric","All")%>>All</td>
</tr>
<tr>
<td><INPUT name="chbpediatric" type="checkbox" value="N/A" <%=check_check("chbpediatric","N/A")%>>N/A</td>
<td><INPUT name="chbpediatric" type="checkbox" value="Other" <%=check_check("chbpediatric","Other")%>>Other</td>
</tr>
<tr><td colSpan="5"><h3><font color="red">* </font>Adults</h3></td></tr>
<tr>
<td><input name="chbadult" type="checkbox" value="Spinal Cord Injury" <%=check_check("chbadult","Spinal Cord Injury")%>>Spinal Cord Injury</td>
<td><input name="chbadult" type="checkbox" value="Multiple Trauma" <%=check_check("chbadult","Multiple Trauma")%>>Multiple Trauma</td>
<td><input name="chbadult" type="checkbox" value="Psychiatric" <%=check_check("chbadult","Psychiatric")%>>Psychiatric</td>
<td><input name="chbadult" type="checkbox" value="Chronic Pain" <%=check_check("chbadult","Chronic Pain")%>>Chronic Pain</td>
</tr>
<tr>
<td><input name="chbadult" type="checkbox" value="Burns" <%=check_check("chbadult","Burns")%>>Burns</font></td>
<td><input name="chbadult" type="checkbox" value="Acquired Brain Injury" <%=check_check("chbadult","Acquired Brain Injury")%>>Acquired Brain Injury</td>
<td><input name="chbadult" type="checkbox" value="All" <%=check_check("chbadult","All")%>>All </td>
<td><input name="chbadult" type="checkbox" value="N/A" <%=check_check("chbadult","N/A")%>>N/A</font> </td>
</tr>
<tr>
<td><input name="chbadult" type="checkbox" value="Toxic Torts" <%=check_check("chbadult","Toxic Torts")%>>Toxic Torts</td>
<td><input name="chbadult" type="checkbox" value="Medicare Set-Asides" <%=check_check("chbadult","Medicare Set-Asides")%>>Medicare Set-Asides</td>
<td><input name="chbadult" type="checkbox" value="Workers Comp" <%=check_check("chbadult","Workers Comp")%>>Workers' Compensation </td>
<td><input name="chbadult" type="checkbox" value="Other" <%=check_check("chbadult","Other")%>>Other</td>
</tr>
</table>
</td>
</tr>
<tr>
<td colSpan="4"><h3>Professional Information: <em style="font-weight:normal; text-decoration:none; ">(if additional information is desired)</em></h3></td>
</tr>
<tr>
<td colSpan="6"><TEXTAREA id="info" name="info" value=""rows="5" cols="70"><%=info%></TEXTAREA></td>
</tr>
<tr><td colSpan="6" height="10"></td></tr>
<% if maint <> true then %>
<tr>
<td colSpan="6" height="10">
<strong>Please type the numbers displayed in the box.</strong>
<table border="0" cellspacing="0" cellpadding="0">
<tr><td>
<%
session("check_str") = ""
dim check_array()
intUpperBound = 9
intLowerBound = 0
redim check_array(4)
for i = 0 to ubound(check_array)
Randomize()
intRangeSize = intUpperBound - intLowerBound + 1
sngRandomValue = intRangeSize * Rnd()
check_array(i) = Int(sngRandomValue)
next
for i = 0 to ubound(check_array)
select case check_array(i)
case 1
img = "dirt.gif"
case 2
img = "musky.gif"
case 3
img = "fartwad.gif"
case 4
img = "crispy.gif"
case 5
img = "noogies.gif"
case 6
img = "meinleben.gif"
case 7
img = "bungie.gif"
case 8
img = "fargle.gif"
case 9
img = "jingle.gif"
case else '0
img = "sparkle.gif"
end select
session("check_str") = session("check_str") & check_array(i)
response.write "<img src=""/images/ver/" & img & """ />"
next
%>
</td><td>
<input type="text" name="verify" size="20" /> <font color="red">* </font>
</td></tr>
</table>
<br>
</td>
</tr>
<% end if %>
<tr>
<td></td>
<% if record_id = "" or record_id = "0" then %>
<td><INPUT type="submit" value="Submit" name="action"><INPUT type="reset" value=" Reset " name="reset"></td>
<% else %>
<td>
Verified: <select name="verified">
<option value="true" <%if verified then %>selected<%end if%>>Yes</option>
<option value="false" <%if not verified then %>selected<%end if%>>No</option>
</select><br><br>
<INPUT type="submit" value="Update" name="action"><INPUT type="submit" value="Delete" name="action" onClick="return confirm('Are you sure you want to delete this record?')"><INPUT type="button" value="Cancel" onClick="document.location='index.asp'"></td>
<% end if %>
</tr>
</table>
<%
function check_check(field_name,field_value)
compare_value = ""
found_value = ""
select case field_name
case "chbdegrees"
compare_value = chbdegrees
case "chbcertifications"
compare_value = chbcertifications
case "practice"
compare_value = practice
case "chbpediatric"
compare_value = chbpediatric
case "chbadult"
compare_value = chbadult
end select
compare_array = split(compare_value,",")
for i = 0 to ubound(compare_array)
if trim(compare_array(i)) = field_value then
found_value = "checked"
end if
next
check_check = found_value
end function
%>
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