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We take this opportunity to thank you for being interested in becoming a blood donor. We really appreciate your effort.
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| And in case you might want some more information, browse through our Assistance page and we will get back to you. |
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insert("blooddonor",$excufld);
if($ans)
$dflag=1;
}
}
if($dflag==1)
{
echo "";
$obj->table("","60%","","lable","","","");
$obj->tr();
echo "
 | ";
echo "You have become our member.
We will contact you very soon. | ";
$obj->ctr();
$obj->ctable();
echo "";
}
?>
0)
{
include("c_error.php");
}
$crntyr=gmdate('Y');
for($i=($crntyr-71); $i <= ($crntyr-18); $i++)
{
$j=$i-($crntyr-72);
$year[$j]=$i;
if($j < 23) $day[$j+9]=$j+9;
}
echo "";
$obj->form("donnor","","post","");
$obj->table("","60%","","tt","lable","","","");
$obj->tr();
$obj->td();
echo "*";
echo "Name:";
echo " First ";
$obj->ctd();
$obj->td();
$obj->tx("fname","15","$fname","txtbx");
echo " Middle ";
$obj->tx("mname","16","$mname","txtbx");
echo " Last ";
$obj->ctd();
$obj->td();
$obj->tx("lname","15","$lname","txtbx");
echo "
";
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "Sex:";
$obj->ctd();
$obj->td();
$obj->dp("sex",$gender,"1","","$sex","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "*";
echo "Date of Birth:";
$obj->ctd();
$obj->td();
$obj->dp("mm",$mon,"1","","$mm","txtbx");
$obj->dp("dd",$day,"1","","$dd","txtbx");
$obj->dp("yy",$year,"1","","$yy","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "Weight:";
$obj->ctd();
$obj->td();
$obj->tx("weight","4","$weight","txtbx");echo "(in kg)";
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "Blood Group:";
$obj->ctd();
$obj->td();
$obj->dp("bldgrp",$bldgrp,"1","","$bldgrp","txtbx");
echo " Rh Factor: ";
$obj->dp("rhfactor1",$rh1,"1","","$rhfactor1","txtbx");
echo " And: ";
$obj->dp("obldgrp",$andbld,"1","","$obld","txtbx");
echo " Rh Factor:";
$obj->ctd();
$obj->td();
$obj->dp("rhfactor2",$rh2,"1","","$rhfactor2","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "E-mail";
echo " 1.";
$obj->ctd();
$obj->td("2");
$obj->tx("email1","33","$email1","txtbx");
echo " 2. ";
$obj->tx("email2","30","$email2","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "Marital Status:";
$obj->ctd();
$obj->td();
$obj->dp("maritual",$mrt,"1","","$maritual","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo " ";
$obj->ctd();
$obj->ctr();
$obj->tr();
echo"";
echo "Contact Information:";
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "Father's Name:";
$obj->ctd();
$obj->td();
$obj->tx("fathername","40","$fathername","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "*";
echo "Address Line1:";
$obj->ctd();
$obj->td("2");
$obj->tx("address1","40","$address1","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "Address Line2:";
$obj->ctd();
$obj->td("2");
$obj->tx("address2","40","$address2","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "City:";
$obj->ctd();
$obj->td();
$obj->tx("cty","15","$cty","txtbx");
echo "
";
echo "State:";
$obj->ctd();
$obj->td();
$obj->tx("state","15","$state","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "Country:";
$obj->ctd();
$obj->td();
$obj->dp("country",$cun,"1","","$country","txtbx");
echo " ";
echo "Zip / Postal Code:";
$obj->ctd();
$obj->td();
$obj->tx("zip","15","","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "Landmark:";
$obj->ctd();
$obj->td();
$obj->tx("landmark","15","$landmark","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "Phone No:";
echo " 1.";
$obj->ctd();
$obj->td();
$obj->tx("phno1","15","$phno1","txtbx");
echo " 2. ";
$obj->tx("phno2","15","$phno2","txtbx");
echo " Mobile:";
$obj->ctd();
$obj->td();
$obj->tx("mblno","15","$mblno","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td("","","","","","top");
echo "Contact Address In Case of Emergency:";
$obj->ctd();
$obj->td("2");
$obj->txr("emraddress","38","4","$emraddress","txtbx");echo "
";
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td("3");
$obj->table("","100%","","lable","","","");
$obj->tr();
echo" | ";
echo "Past Disease Information:";
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "Disease Name:";
$obj->ctd();
$obj->td("2","","","","center");
echo "Period: (mm/dd/yyyy)";
$obj->ctd();
$obj->td();
echo "Disease Details:";
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
$obj->ctd();
$obj->td();
echo "From";
$obj->ctd();
$obj->td();
echo " To ";
$obj->ctd();
$obj->td();
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
$obj->tx("dz1","15","$dz1","txtbx");
$obj->ctd();
$obj->td();
$obj->tx("stdt1","10","$stdt1","txtbx");
$obj->ctd();
$obj->td();
echo " - ";
$obj->tx("enddt1","10","$enddt1","txtbx");
$obj->ctd();
$obj->td();
$obj->txr("detail1","","1","$detail1","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
$obj->tx("dz2","15","$dz2","txtbx");
$obj->ctd();
$obj->td();
$obj->tx("stdt2","10","$stdt2","txtbx");
$obj->ctd();
$obj->td();
echo " - ";
$obj->tx("enddt2","10","$enddt2","txtbx");
$obj->ctd();
$obj->td();
$obj->txr("detail2","","1","$detail2","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
$obj->tx("dz3","15","$dz3","txtbx");
$obj->ctd();
$obj->td();
$obj->tx("stdt3","10","$stdt3","txtbx");
$obj->ctd();
$obj->td();
echo " - ";
$obj->tx("enddt3","10","$enddt3","txtbx");
$obj->ctd();
$obj->td();
$obj->txr("detail3","","1","$detail3","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
$obj->tx("dz4","15","$dz4","txtbx");
$obj->ctd();
$obj->td();
$obj->tx("stdt4","10","$stdt4","txtbx");
$obj->ctd();
$obj->td();
echo " - ";
$obj->tx("enddt4","10","$enddt4","txtbx");
$obj->ctd();
$obj->td();
$obj->txr("detail4","","1","$detail4","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
$obj->tx("dz5","15","$dz5","txtbx");
$obj->ctd();
$obj->td();
$obj->tx("stdt5","10","$stdt5","txtbx");
$obj->ctd();
$obj->td();
echo " - ";
$obj->tx("enddt5","10","$enddt5","txtbx");
$obj->ctd();
$obj->td();
$obj->txr("detail5","","1","$detail5","txtbx");
$obj->ctd();
$obj->ctr();
$obj->ctable();
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td("4");
echo "Can we contact you in case of blood donation need ? ";
$obj->dp("contact",$contact,"1","","","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo " ";
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td("4","","","","middle");
$obj->sb("Submit","Submit");echo " ";
$obj->rs("Reset","Reset");
$obj->ctd();
$obj->ctr();
$obj->ctable();
echo "";
$obj->cform();
}
?>
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