Code: Select all
<html>
<head>
<title>YMCA/JCP Pool Members Database</title>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1">
<style type="text/css">
<!--
.text {
font-family: "Times New Roman", Times, serif;
font-size: 10px;
color: #000000;
}
-->
</style>
</head>
<body>
<div align="center">
<form name="form1" method="post" action="form1.php">
<table width="0" border="1" cellpadding="00" cellspacing="0" bordercolor="#000000">
<tr>
<td width="500" height="722">
<table width="500" height="129" border="1" cellpadding="0" cellspacing="10" bordercolor="#FFFFFF">
<tr bordercolor="#FFFFFF">
<td nowrap bgcolor="#EBEBEB">
<div align="left"><font size="2">Search Members<font face="Times New Roman, Times, serif">
</font></font> </div>
</td>
<td height="12" rowspan="3" nowrap bordercolor="#000000">
<div align="center"><img src="images/mysql.jpg" width="167" height="87"></div></td>
</tr>
<tr bordercolor="#FFFFFF">
<td width="204" height="53" nowrap><font size="2"><font face="Times New Roman, Times, serif">
<input name="search" type="text" id="search" size="29">
<input name="membersearch" type="submit" id="membersearch" value="Search">
</font></font></td>
</tr>
<tr bordercolor="#FFFFFF">
<td height="17" nowrap bgcolor="#EBEBEB"><font size="2"><a href="mailto:sdiver1500@aol.com">Contact
Administrator</a></font></td>
</tr>
</table>
<table width="500" height="1" border="0" cellpadding="0" cellspacing="0">
<tr>
<td height="1" bgcolor="#000000"></td>
</tr>
</table>
<table width="500" border="1" cellpadding="0" cellspacing="10" bordercolor="#FFFFFF">
<tr>
<td bgcolor="#EBEBEB" class="text"><font color="#FF0000" size="2">*</font><font size="2">
Notes Required Feilds</font></td>
</tr>
</table>
<table width="501" border="1" cellpadding="0" cellspacing="10" bordercolor="#FFFFFF">
<tr align="left" valign="top" class="text">
<td width="225" height="0" nowrap bgcolor="#EBEBEB" class="text">
<div align="left" class="text"><font size="2"></font><font size="2" face="Times New Roman, Times, serif">Last
Name:</font></div></td>
<td width="68" height="0" nowrap bgcolor="#FFFFFF"> </td>
<td width="160" height="0" nowrap bgcolor="#EBEBEB"><div align="left" class="text"><font size="2" face="Times New Roman, Times, serif">Home
Phone Number:</font></div></td>
</tr>
<tr align="left" valign="top" class="text">
<td width="225" height="0" nowrap><div align="left"><font size="2" face="Times New Roman, Times, serif">
</font><font size="2" face="Times New Roman, Times, serif">
<input name="lastname" type="text" id="lastname" size="30" maxlength="30">
</font><font color="#FF0000" size="2">*</font><font size="2" face="Times New Roman, Times, serif">
</font></div></td>
<td width="68" height="0" nowrap bgcolor="#FFFFFF"> </td>
<td width="160" height="0" nowrap><div align="left"><font size="2" face="Times New Roman, Times, serif">
<input name="homenum" type="text" id="homenum" size="12" maxlength="12">
<br>
</font><font color="#FF0000" size="2">*</font><font size="1" face="Times New Roman, Times, serif">ect:
904-287-5555</font></div></td>
</tr>
<tr align="left" valign="top" class="text">
<td width="225" height="0" nowrap bgcolor="#EBEBEB"><div align="left" class="text"><font size="2"></font><font size="2" face="Times New Roman, Times, serif">Adults'
Names</font></div></td>
<td width="68" height="0" nowrap bgcolor="#FFFFFF"> </td>
<td width="160" height="0" nowrap bgcolor="#EBEBEB"><div align="left"><font size="2"></font><font size="2" face="Times New Roman, Times, serif">Work
Phone Number</font></div></td>
</tr>
<tr align="left" valign="top" class="text">
<td width="225" height="0" nowrap><div align="left"><font size="2" face="Times New Roman, Times, serif">
<input name="1adultname" type="text" id="1adultname" size="30" maxlength="30">
</font><br>
<font color="#FF0000" size="2">*</font> </div></td>
<td width="68" height="0" nowrap bgcolor="#FFFFFF"> </td>
<td width="160" height="0" nowrap><div align="left"><font size="2" face="Times New Roman, Times, serif">
<input name="1worknum" type="text" id="1worknum" size="12" maxlength="12">
<br>
</font><font color="#FF0000" size="2">*</font><font size="1" face="Times New Roman, Times, serif">ect:
904-287-5555</font></div></td>
</tr>
<tr align="left" valign="top" class="text">
<td width="225" height="0" nowrap><div align="left"><font size="2" face="Times New Roman, Times, serif">
<input name="2adultname" type="text" id="2adultname" size="30" maxlength="30">
</font></div></td>
<td width="68" height="0" nowrap bgcolor="#FFFFFF"> </td>
<td width="160" height="0" nowrap><div align="left"><font size="2" face="Times New Roman, Times, serif">
<input name="2worknum" type="text" id="2worknum" size="12" maxlength="12">
<br>
<font size="1">ect: 904-287-5555 </font></font></div></td>
</tr>
<tr align="left" valign="top" class="text">
<td width="225" height="0" nowrap bgcolor="#EBEBEB"><div align="left"><font size="2" face="Times New Roman, Times, serif">First
Name(s) of Children Living at Home</font></div></td>
<td width="68" height="0" nowrap bgcolor="#EBEBEB"><div align="left"><font size="2" face="Times New Roman, Times, serif">Age</font></div></td>
<td width="160" height="0" nowrap bgcolor="#EBEBEB"><div align="left"><font size="2" face="Times New Roman, Times, serif">Birthdate</font></div></td>
</tr>
<tr align="left" valign="top" class="text">
<td width="225" height="0" nowrap><div align="left"><font size="2" face="Times New Roman, Times, serif">
<input name="1childname" type="text" id="1childname" size="30" maxlength="30">
</font></div></td>
<td width="68" height="0" nowrap><div align="left"><font size="2" face="Times New Roman, Times, serif">
<select name="1childage" size="1" id="1childage">
<option value=" " selected> </option>
<option value="01">0-1 Year</option>
<option value="02">2 Years</option>
<option value="03">3 Years</option>
<option value="04">4 Years</option>
<option value="05">5 Years</option>
<option value="06">6 Years</option>
<option value="07">7 Years</option>
<option value="08">8 years</option>
<option value="09">9 Years</option>
<option value="10">10 Years</option>
<option value="11">11 Years</option>
<option value="12">12 Years</option>
<option value="13">13 Years</option>
<option value="14">14 Years</option>
<option value="15">15 Years</option>
<option value="16">16 Years</option>
<option value="17">17 Years</option>
</select>
</font></div></td>
<td width="160" height="0" nowrap><div align="left"><font size="1" face="Times New Roman, Times, serif">
<font size="2">
<input name="1childbd" type="text" id="1childbd" size="8" maxlength="8">
</font><br>
ect: MMDDYYYY </font></div></td>
</tr>
<tr align="left" valign="top" class="text">
<td width="225" height="0" nowrap><div align="left"><font size="2" face="Times New Roman, Times, serif">
<input name="2childname" type="text" id="2childname" size="30" maxlength="30">
</font></div></td>
<td width="68" height="0" nowrap><div align="left"><font size="2" face="Times New Roman, Times, serif">
<select name="2childage" size="1" id="2childage">
<option value=" " selected> </option>
<option value="01">0-1 Year</option>
<option value="02">2 Years</option>
<option value="03">3 Years</option>
<option value="04">4 Years</option>
<option value="05">5 Years</option>
<option value="06">6 Years</option>
<option value="07">7 Years</option>
<option value="08">8 years</option>
<option value="09">9 Years</option>
<option value="10">10 Years</option>
<option value="11">11 Years</option>
<option value="12">12 Years</option>
<option value="13">13 Years</option>
<option value="14">14 Years</option>
<option value="15">15 Years</option>
<option value="16">16 Years</option>
<option value="17">17 Years</option>
</select>
</font></div></td>
<td width="160" height="0" nowrap><div align="left"><font size="1" face="Times New Roman, Times, serif">
<font size="2">
<input name="2childbd" type="text" id="2childbd" size="8" maxlength="8">
</font><br>
ect: MMDDYYYY </font></div></td>
</tr>
<tr align="left" valign="top" class="text">
<td width="225" height="0" nowrap><div align="left"><font size="2" face="Times New Roman, Times, serif">
<input name="3childname" type="text" id="3childname" size="30" maxlength="30">
</font></div></td>
<td width="68" height="0" nowrap><div align="left"><font size="2" face="Times New Roman, Times, serif">
<select name="3childage" size="1" id="3childage">
<option value=" " selected> </option>
<option value="01">0-1 Year</option>
<option value="02">2 Years</option>
<option value="03">3 Years</option>
<option value="04">4 Years</option>
<option value="05">5 Years</option>
<option value="06">6 Years</option>
<option value="07">7 Years</option>
<option value="08">8 years</option>
<option value="09">9 Years</option>
<option value="10">10 Years</option>
<option value="11">11 Years</option>
<option value="12">12 Years</option>
<option value="13">13 Years</option>
<option value="14">14 Years</option>
<option value="15">15 Years</option>
<option value="16">16 Years</option>
<option value="17">17 Years</option>
</select>
</font></div></td>
<td width="160" height="0" nowrap><div align="left"><font size="1" face="Times New Roman, Times, serif">
<font size="2">
<input name="3childbd" type="text" id="3childbd" size="8" maxlength="8">
</font><br>
ect: MMDDYYYY </font></div></td>
</tr>
<tr align="left" valign="top" class="text">
<td width="225" height="0" nowrap><div align="left"><font size="2" face="Times New Roman, Times, serif">
<input name="4childname" type="text" id="4childname" size="30" maxlength="30">
</font></div></td>
<td width="68" height="0" nowrap><div align="left"><font size="2" face="Times New Roman, Times, serif">
<select name="4childage" size="1" id="4childage">
<option value=" " selected> </option>
<option value="01">0-1 Year</option>
<option value="02">2 Years</option>
<option value="03">3 Years</option>
<option value="04">4 Years</option>
<option value="05">5 Years</option>
<option value="06">6 Years</option>
<option value="07">7 Years</option>
<option value="08">8 years</option>
<option value="09">9 Years</option>
<option value="10">10 Years</option>
<option value="11">11 Years</option>
<option value="12">12 Years</option>
<option value="13">13 Years</option>
<option value="14">14 Years</option>
<option value="15">15 Years</option>
<option value="16">16 Years</option>
<option value="17">17 Years</option>
</select>
</font></div></td>
<td width="160" height="0" nowrap><div align="left"><font size="1" face="Times New Roman, Times, serif">
<font size="2">
<input name="4childbd" type="text" id="4childbd" size="8" maxlength="8">
</font><br>
ect: MMDDYYYY </font></div></td>
</tr>
<tr align="left" valign="top" class="text">
<td width="225" height="0" nowrap><div align="left"><font size="2" face="Times New Roman, Times, serif">
<input name="5childname" type="text" id="5childname" size="30" maxlength="30">
</font></div></td>
<td width="68" height="0" nowrap><div align="left"><font size="2" face="Times New Roman, Times, serif">
<select name="5childage" size="1" id="5childage">
<option value=" " selected> </option>
<option value="01">0-1 Year</option>
<option value="02">2 Years</option>
<option value="03">3 Years</option>
<option value="04">4 Years</option>
<option value="05">5 Years</option>
<option value="06">6 Years</option>
<option value="07">7 Years</option>
<option value="08">8 years</option>
<option value="09">9 Years</option>
<option value="10">10 Years</option>
<option value="11">11 Years</option>
<option value="12">12 Years</option>
<option value="13">13 Years</option>
<option value="14">14 Years</option>
<option value="15">15 Years</option>
<option value="16">16 Years</option>
<option value="17">17 Years</option>
</select>
</font></div></td>
<td width="160" height="0" nowrap><div align="left"><font size="1" face="Times New Roman, Times, serif">
<font size="2">
<input name="5childbd" type="text" id="5childbd" size="8" maxlength="8">
</font><br>
ect: MMDDYYYY </font></div></td>
</tr>
</table>
<table width="500" border="1" cellpadding="0" cellspacing="10" bordercolor="#FFFFFF">
<tr>
<td class="text"><font size="2" face="Times New Roman, Times, serif"> <font size="4">T</font>he
undersigned agrees and acknowledges that the above information is
true and correct. It is understood that User and Guest cards are
the property of the Julington Creek Plantation Community Development
District (JCPCDD) and are non-transferable except in accordance
with the District's rules, policies and/or regulations. in consideration
for the admittance of the above listed persons and their guests
into the Plantation Club facility owned and operated by the JCPCDD
the undersigned agrees to hold harmless and release the JCPCDD,
its agents, officers and employees, from any and all liability for
any injuries that might occur in conjunction with usage of the Plantation
Club. Nothing herein shall be construed as a waiver of the District's
sovereign immunity or limits of liability beyond any statutory limited
waiver of immunity or limits of liability which may have been adopted
by the Florida Legislature in Section 768.28, Florida Statutes or
other statute.</font></td>
</tr>
</table>
<table width="500" height="302" border="1" cellpadding="00" cellspacing="10" bordercolor="#FFFFFF">
<tr align="left" valign="top">
<td height="17" nowrap bgcolor="#EBEBEB" class="text" span="1"> <div align="left"><font size="2"></font><font size="2" face="Times New Roman, Times, serif">Name
of Applicant</font></div></td>
<td width="67%" colspan="2" rowspan="8" align="center" valign="middle" nowrap bordercolor="#000000" bgcolor="#FFFFFF" class="text"> <img src="images/ymcalogo.gif" width="100" height="175"></td>
</tr>
<tr align="left" valign="top">
<td width="33%" height="0" nowrap class="text" span="1"> <div align="left"><font size="2" face="Times New Roman, Times, serif">
<input name="appname" type="text" id="appname" size="30" maxlength="30">
</font><font color="#FF0000" size="2"><br>
*</font><font size="2" face="Times New Roman, Times, serif">
</font></div></td>
</tr>
<tr align="left" valign="top">
<td width="33%" height="0" nowrap bgcolor="#EBEBEB" class="text"span="1">
<div align="left"><font size="2"></font><font size="2" face="Times New Roman, Times, serif">Signature</font></div></td>
</tr>
<tr align="left" valign="top">
<td width="33%" height="-5" class="text" span="1"> <div align="left"><font size="2" face="Times New Roman, Times, serif"> </font><font color="#FF0000" size="2">*</font><font size="2" face="Times New Roman, Times, serif">
<input name="appsig" type="checkbox" id="appsig" value="yes">
By checking this box you acknowlage that it has the same binding
power as your signature and is equal to your signature in every
other way.</font></div></td>
</tr>
<tr align="left" valign="top">
<td height="-5" bgcolor="#EBEBEB" class="text" span="1"><font size="2"> </font><font size="2">Date</font></td>
</tr>
<tr align="left" valign="top">
<td height="0" class="text" span="1"><font size="2" face="Times New Roman, Times, serif">
<input name="appdate" type="text" id="appdate" size="8" maxlength="8">
<br>
</font><font color="#FF0000" size="2">*</font><font size="1" face="Times New Roman, Times, serif">ect:
MMDDYYYY</font></td>
</tr>
<tr align="left" valign="top">
<td height="0" nowrap bgcolor="#EBEBEB" class="text" span="1"> <div align="left" class="text"><font color="#FF0000" size="2"><font color="#000000">Street</font>
</font><font size="2" face="Times New Roman, Times, serif">Address
</font></div></td>
</tr>
<tr align="left" valign="top">
<td height="0" nowrap class="text"> <div align="left"><font size="2" face="Times New Roman, Times, serif">
<input name="address" type="text" id="address" size="30" maxlength="50">
</font><font color="#FF0000" size="2"><br>
*</font><font size="2" face="Times New Roman, Times, serif">
</font></div></td>
</tr>
</table>
<table width="500" border="1" cellpadding="0" cellspacing="10" bordercolor="#FFFFFF">
<tr bordercolor="#FFFFFF" bgcolor="#EBEBEB" class="text">
<td width="108" bgcolor="#EBEBEB"><font size="2"> </font><font size="2">Card
Numbers</font></td>
<td width="107"><font size="2"> </font><font size="2">Guest
Card </font></td>
<td width="109"><font size="2">Check Number</font></td>
<td width="98"><font size="2"> </font><font size="2">Date Paid</font></td>
</tr>
<tr align="left" valign="top" bordercolor="#FFFFFF">
<td width="108" height="37"><font size="2" face="Times New Roman, Times, serif">
<input name="cardnum" type="text" id="cardnum" size="9" maxlength="9">
<br>
</font><font color="#FF0000" size="2">*</font><font size="1" face="Times New Roman, Times, serif">ect:
0000001-2</font></td>
<td width="107"><font size="2" face="Times New Roman, Times, serif">
<input name="guestnum" type="text" id="guestnum" size="7" maxlength="7">
</font><font color="#FF0000" size="2"><br>
*</font><font size="2" face="Times New Roman, Times, serif">
</font></td>
<td width="109"><font size="2" face="Times New Roman, Times, serif">
<input name="checknum" type="text" id="checknum" size="10" maxlength="10">
<br>
</font><font color="#FF0000" size="2">*</font><font size="2" face="Times New Roman, Times, serif">
</font></td>
<td width="98"><font size="2" face="Times New Roman, Times, serif">
<input name="datepaid" type="text" id="datepaid" size="8" maxlength="8">
<br>
</font><font color="#FF0000" size="2">*</font><font size="1" face="Times New Roman, Times, serif">ect:
MMDDYYYY</font></td>
</tr>
</table>
<table width="500" height="0" border="1" cellpadding="0" cellspacing="10" bordercolor="#FFFFFF">
<tr bordercolor="#FFFFFF">
<td width="0" height="0">
<input name="formreset" type="reset" id="formreset" value="Reset">
<div align="right"> </div></td>
<td><div align="center"></div></td>
<td width="0">
<div align="right">
<input name="formsubmit" type="submit" id="formsubmit" value="Submit">
</div></td>
</tr>
</table>
</td>
</tr>
</table>
</form>
</div>
</body>
</html>