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206 lines (201 loc) · 7.82 KB
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<?php include 'header.php';?>
<!------- add page here -------->
<center>
<form action="add2.php" method="POST" name="add1">
<table style="width:300px;" border="0">
<tr>
<td width="111" align="right">
<br>
</td>
<td align="center" colspan="3">
<font color="darkblue" size="4">Add a Contact</font><br><br /><br />
</td>
</tr>
<tr>
<td width="111" align="right">
First Name:
</td>
<td align="left" colspan="3">
<INPUT name="first" id="first"
style="WIDTH: 100%; HEIGHT: 22px; background-color: white; color: darkblue;"
size=56 required
oninvalid="this.setCustomValidity('Please enter the first name of the contact');"
onchange="try{setCustomValidity('')}catch(e){};" x-moz-errormessage="Please enter the first name of the contact">
</td>
</tr>
<tr>
<td align="right" nowrap>
Last Name:
</td>
<td align="left" colspan="3">
<INPUT name="last" id="last"
style="WIDTH: 100%; HEIGHT: 22px; background-color: white; color: darkblue;"
size=56 required
oninvalid="this.setCustomValidity('Please enter the last name of the contact');"
onchange="try{setCustomValidity('')}catch(e){};" x-moz-errormessage="Please enter the last name of the contact">
</td>
</tr>
<tr>
<td align="right" nowrap>
Gender:
</td>
<td width="100">
<select size="1"
name="gender" required
style="WIDTH: 125px; HEIGHT: 22px; background-color: white; color: darkblue;">
<option value="">Select Gender</option>
<option value="Male">Male</option>
<option value="Female">Female</option>
</select>
</td>
<td width="104" align="right">
Age:
</td>
<td width="50">
<INPUT name="age" id="age"
style="WIDTH: 50px; HEIGHT: 22px; background-color: white; color: darkblue;"
size=56 required
oninvalid="this.setCustomValidity('Please enter the age of the contact');"
onchange="try{setCustomValidity('')}catch(e){};" x-moz-errormessage="Please enter the age of the contact">
</td>
</tr>
<tr>
<td align="right" nowrap>
Email Address:
</td>
<td align="left" colspan="3">
<INPUT name="email"
style="WIDTH: 100%; HEIGHT: 22px; background-color: white; color: darkblue;"
size=56 required
oninvalid="this.setCustomValidity('Please enter the email address of the contact');"
onchange="try{setCustomValidity('')}catch(e){};" x-moz-errormessage="Please enter the email address of the contact">
</td>
</tr>
<tr>
<td align="right" nowrap>
Street Address:
</td>
<td colspan="3">
<INPUT name="address"
style="WIDTH: 100%; HEIGHT: 22px; background-color: white; color: darkblue;"
size=56 required
oninvalid="this.setCustomValidity('Please enter the street address of the contact');"
onchange="try{setCustomValidity('')}catch(e){};" x-moz-errormessage="Please enter the street address of the contact">
</td>
</tr>
<tr>
<td align="right" nowrap>
City:
</td>
<td align="left" colspan="3">
<INPUT name="city"
style="WIDTH: 100%; HEIGHT: 22px; background-color: white; color: darkblue;"
size=56 required
oninvalid="this.setCustomValidity('Please enter the city of the contact');"
onchange="try{setCustomValidity('')}catch(e){};" x-moz-errormessage="Please enter the city of the contact">
</td>
</tr>
<tr>
<td align="right" nowrap>
State:
</td>
<td align="left">
<INPUT name="state"
style="WIDTH: 100px; HEIGHT: 22px; background-color: white; color: darkblue;"
size=56 required minlength="2" maxlength="2"
oninvalid="this.setCustomValidity('Please enter the abreviation of the state or providence');"
onchange="try{setCustomValidity('')}catch(e){};" x-moz-errormessage="Please enter the abreviation of the state or providence">
</td>
<td align="right" nowrap>
Postal Code:
</td>
<td>
<INPUT name="zip"
style="WIDTH: 50px; HEIGHT: 22px; background-color: white; color: darkblue;"
size=56 required
oninvalid="this.setCustomValidity('Please enter the Postal Code of the contact');"
onchange="try{setCustomValidity('')}catch(e){};" x-moz-errormessage="Please enter the age of the contact">
</td>
</tr>
<tr>
<td align="right" nowrap>
County:
</td>
<td align="left" colspan="3">
<INPUT name="county"
style="WIDTH: 100%; HEIGHT: 22px; background-color: white; color: darkblue;"
size=56 required
oninvalid="this.setCustomValidity('Please enter the county name of the contact');"
onchange="try{setCustomValidity('')}catch(e){};" x-moz-errormessage="Please enter the county name of the contact">
</td>
</tr>
<tr>
<td align="right" nowrap>
Phone:
</td>
<td align="left" colspan="3">
<INPUT name="phone"
style="WIDTH: 100%; HEIGHT: 22px; background-color: white; color: darkblue;px"
size=56 required
oninvalid="this.setCustomValidity('Please enter the age of the contact');"
onchange="try{setCustomValidity('')}catch(e){};" x-moz-errormessage="Please enter the age of the contact">
</td>
</tr>
<tr>
<td align="right" nowrap="nowrap">
Willing to Bridge:
</td>
<td align="left">
<select size="1"
name="interest" required
style="WIDTH: 150px; HEIGHT: 26px; background-color: white; color: darkblue;">
<option value="">Select Facility Type</option>
<option value="Both">Both</option>
<option value="Corrections">Corrections</option>
<option value="Treatment">Treatment</option>
</select>
</td>
<?php if ($_SESSION['adminlevel'] < 2) { ?>
<td colspan=2>
<input type="hidden" value="<?php echo $_SESSION['district']?>" name="district">
</td>
<?php } else { ?>
<td align="right" colspan="1" nowrap>
District:
</td>
<td align="left">
<INPUT name="district"
style="WIDTH: 50px; HEIGHT: 22px; background-color: white; color: darkblue;"
size=4 required
oninvalid="this.setCustomValidity('Please enter the district or region of the contact');"
onchange="try{setCustomValidity('')}catch(e){};" x-moz-errormessage="Please enter the district or region of the contact">
</td>
<?php } ?>
</tr>
<tr>
<td align="right" nowrap>
Spanish Speaking
</td>
<td nowrap colspan="3">
<input type="checkbox" name="flang">
Other Language:
<INPUT name="olang"
style="WIDTH: 50px; HEIGHT: 22px; background-color: white; color: darkblue;"
size=56>
</td>
</tr>
<tr>
<td>
<br>
</td>
<td align="center" colspan="3">
<input type="Submit" value="Add Contact" name="b2">
</td>
</tr>
</table>
</form>
</center>
<!------- end page here ------------>
</body>
</html>