:: Warrior Lacrosse Camp

<% Response.CacheControl = "no-cache" Response.AddHeader "Pragma", "no-cache" Response.Expires = -1 %> <% Function CheckCAPTCHA(valCAPTCHA) SessionCAPTCHA = Trim(Session("CAPTCHA")) Session("CAPTCHA") = vbNullString if Len(SessionCAPTCHA) < 1 then CheckCAPTCHA = False exit function end if if CStr(SessionCAPTCHA) = CStr(valCAPTCHA) then CheckCAPTCHA = True else CheckCAPTCHA = False end if End Function %> :: Warrior Lacrosse Camp :: Home <% If request.form("submit") = "True" then Response.Write("Hi") txtMethod = request.form("txtMethod") txtCCAmount = request.form("txtCCAmount") Set regEmail = Server.CreateObject("CDONTS.NewMail") regEmail.from = "webform@warriorlacrossecamp.com" regEmail.bodyformat = 1 regEmail.mailformat = 1 regEmail.To = "webkey@gmail.com" regEmail.Subject = "Student Registration" txtEmailBody = "Player Information:" &_ vbcrlf & vbcrlf & "Name: " & request.form("txtFirst") & " " & request.form("txtLast") &_ vbcrlf & "Address: " & request.form("txtStreet") &_ vbcrlf & request.form("txtCity") & ", " & request.form("txtState") & " " & request.form("txtZip") &_ vbcrlf & "Phone: " & request.form("txtPhone") &_ vbcrlf & "Parent Cell Phome: " & request.form("txtMobile") &_ vbcrlf & "School: " & request.form("txtSchool") &_ vbcrlf & "Grade: " & request.form("txtGrade") &_ vbcrlf & "Height: " & request.form("txtHeight") &_ vbcrlf & "Weight: " & request.form("txtWeight") &_ vbcrlf & "Experience: " & request.form("txtYears") & " years" &_ vbcrlf & "Player Date of Birth: " & request.form("txtDob") &_ vbcrlf & "Shirt Size: " & request.form("txtSize") &_ vbcrlf & "Position: " & request.form("txtPosition") &_ vbcrlf & "Payment Option: " & request.form("txtPayment") &_ vbcrlf & "Roommate: " & request.form("txtRoommate") &_ vbcrlf & vbcrlf & "Medical Information: " &_ vbcrlf & "Allergies: " & request.form("txtAllergies") &_ vbcrlf & "Current Medications: " & request.form("txtMeds") &_ vbcrlf & "Past Illness: " & request.form("txtIllness") &_ vbcrlf & "Comments: " & request.form("txtComments") &_ vbcrlf & "Physician Name: " & request.form("txtDocName") &_ vbcrlf & "Physician Address: " & request.form("txtDocAddy") &_ vbcrlf & request.form("txtDocCity") & ", " & request.form("txtDocState") & " " & request.form("txtDocZip") &_ vbcrlf & "Last Tetanus Shot: " & request.form("txtTet") &_ vbcrlf & "Insurance Carrier: " & request.form("txtCarrier") &_ vbcrlf & "Policy Number: " & request.form("txtPolicy") &_ vbcrlf & "Emergency Phone: " & request.form("txtEPhone") &_ vbcrlf & vbcrlf & "Payment Information: " &_ vbcrlf & "Payment Method: " & request.form("txtMethod") &_ vbcrlf & "Credit Card Type: " & request.form("txtCCType") &_ vbcrlf & "Credit Card Name: " & request.form("txtCCName") &_ vbcrlf & "Card Number: " & request.form("txtCCNumber") &_ vbcrlf & "Card Exp: " & request.form("txtCCExp") &_ vbcrlf & "Payment Amount: " & txtCCAmount regEmail.Body = txtEmailBody regEmail.importance=1 regEmail.Send set regEmail = nothing blnSent = 1 End If %>

<% If blnSent = 1 then %>

<%end if%>

<% else %>

<% if Request.ServerVariables("REQUEST_METHOD") = "POST" then strCAPTCHA = Trim(Request.Form("strCAPTCHA")) if CheckCAPTCHA(strCAPTCHA) = true then %> <% Response.Redirect("thanks.htm") %> <% else %> <% Response.Redirect("error.htm") %> <% end if end if %>

Player Information
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Phone:
Parent Cell Phone:
Requested Roommate:

School Attending:

Grade in 2008:

Height:

Weight:

Years of experience:

Player Date of Birth:

Requested Position:

Attack			Midfield
Defense			Goalie

T-Shirt Size (reversible jersey):

Medium			Large
X-Large

Medical Information

Allergies:
Current Medications:
Physical Limitations:
Significant past illness or injury:
Comments / Special Problems:

Physician's Name:
Physician's Address:
Physician's City:
Physician's State:
Physician's Zip Code:

Date of last Tetanus shot:
Insurance Carrier:
Policy Number:
Emergency Contact Phone Number:

Payment Options

		Day Camper - $100 Deposit
		Overnight Camper - $100 Deposit
		Day Camper - $445 Full Payment
		Overnight Camper - $585 Full Payment
		Goalie - Day Camper - $345 Full Payment
		Goalie - Overnight Camper - $435 Full Payment
(Balance of payment is due four weeks before camp, if deposit option is selected.)
Payment Methods

Credit Card
	Type of Card:	Visa
		Mastercard
	Name on Card:
	Card Number:
	Exp Date (mm/yy):
	Payment Amount:

Check
	Make checks payable to:	Warrior Lacrosse Camp L.L.C.
	Mail to:	Warrior Lacrosse Camp 22936 Doremus St. Clair shores, Michigan 48080

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<% End If %>