<%@LANGUAGE="VBSCRIPT"%>
<!--#include file="Connections/pwcn_database.asp" -->
<%
Dim MM_editAction
MM_editAction = CStr(Request.ServerVariables("SCRIPT_NAME"))
If (Request.QueryString <> "") Then
  MM_editAction = MM_editAction & "?" & Server.HTMLEncode(Request.QueryString)
End If

' boolean to abort record edit
Dim MM_abortEdit
MM_abortEdit = false
%>
<%
' IIf implementation
Function MM_IIf(condition, ifTrue, ifFalse)
  If condition = "" Then
    MM_IIf = ifFalse
  Else
    MM_IIf = ifTrue
  End If
End Function
%>
<%
If (CStr(Request("MM_insert")) = "form1") Then
  If (Not MM_abortEdit) Then
    ' execute the insert
    Dim MM_editCmd

    Set MM_editCmd = Server.CreateObject ("ADODB.Command")
    MM_editCmd.ActiveConnection = MM_pwcn_database_STRING
    MM_editCmd.CommandText = "INSERT INTO tbltemp_Contacts (FirstName, LastName, Address1, Address2, City, [State], ZipCode, Country, OutsideUSAddress1, OutsideUSAddress2, OutsideUSAddress3, OutsideUSAddress4, OutsideUSAddress5, Phone, TimetoContact, Fax, Email, [Language], Methodofcontact, TypeofCancer, StageofCancer, TypeofBreastCancer, DateDiagnosed, WeeksPreg, Surgery, TypeofTreatment, OtherTreatment, AgeatDiagnosed, SpeakingwSW, ContactwSW, SendMail, SendInfoPkg, DetailedRequest, Feedback, HowFoundPWCN, OtherHowFound, InterestedSW) VALUES (?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?, ?)" 
    MM_editCmd.Prepared = true
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param1", 202, 1, 50, Request.Form("FirstName")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param2", 202, 1, 100, Request.Form("LastName")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param3", 202, 1, 200, Request.Form("Address1")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param4", 202, 1, 200, Request.Form("Address2")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param5", 202, 1, 50, Request.Form("City")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param6", 202, 1, 50, Request.Form("State")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param7", 202, 1, 50, Request.Form("ZipCode")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param8", 202, 1, 50, Request.Form("Country")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param9", 202, 1, 200, Request.Form("OutsideUSAddress1")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param10", 202, 1, 200, Request.Form("OutsideUSAddress2")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param11", 202, 1, 200, Request.Form("OutsideUSAddress3")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param12", 202, 1, 200, Request.Form("OutsideUSAddress4")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param13", 202, 1, 200, Request.Form("OutsideUSAddress5")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param14", 202, 1, 50, Request.Form("Phone")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param15", 202, 1, 50, Request.Form("TimetoContact")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param16", 202, 1, 50, Request.Form("Fax")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param17", 202, 1, 100, Request.Form("Email")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param18", 202, 1, 50, Request.Form("Language")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param19", 202, 1, 50, Request.Form("Methodofcontact")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param20", 202, 1, 200, Request.Form("TypeofCancer")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param21", 202, 1, 200, Request.Form("StageofCancer")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param22", 202, 1, 200, Request.Form("TypeofBreastCancer")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param23", 202, 1, 50, Request.Form("DateDiagnosed")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param24", 202, 1, 50, Request.Form("WeeksPreg")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param25", 202, 1, 100, Request.Form("Surgery")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param26", 202, 1, 200, Request.Form("TypeofTreatment")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param27", 202, 1, 200, Request.Form("OtherTreatment")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param28", 202, 1, 50, Request.Form("AgeatDiagnosed")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param29", 5, 1, -1, MM_IIF(Request.Form("SpeakingwSW"), 1, 0)) ' adDouble
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param30", 5, 1, -1, MM_IIF(Request.Form("ContactwSW"), 1, 0)) ' adDouble
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param31", 5, 1, -1, MM_IIF(Request.Form("SendMail"), 1, 0)) ' adDouble
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param32", 5, 1, -1, MM_IIF(Request.Form("SendInfoPkg"), 1, 0)) ' adDouble
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param33", 203, 1, 1073741823, Request.Form("DetailedRequest")) ' adLongVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param34", 203, 1, 1073741823, Request.Form("Feedback")) ' adLongVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param35", 202, 1, 100, Request.Form("HowFoundPWCN")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param36", 202, 1, 100, Request.Form("OtherHowFound")) ' adVarWChar
    MM_editCmd.Parameters.Append MM_editCmd.CreateParameter("param37", 5, 1, -1, MM_IIF(Request.Form("InterestedSW"), 1, 0)) ' adDouble
    MM_editCmd.Execute
    MM_editCmd.ActiveConnection.Close

Set myMail=CreateObject("CDO.Message") 
myMail.Subject="Pregnant With Cancer Contact Form Submission" 
myMail.From="info@pregnantwithcancer.org" 
myMail.To="info@pregnantwithcancer.org" 
myMail.TextBody="A new volunteer request has been submitted by:" & vbcrlf & "FirstName:" & " " & request.form("FirstName") & vbcrlf & "LastName:" & " " & request.form("LastName") & vbcrlf & "Address 1:" & " " & request.form("Address1") & vbcrlf & "Address 2:" & " " & request.form("Address2") & vbcrlf &"city:" & " " & request.form("city") & vbcrlf & "State:" & " " & request.form("State") & vbcrlf & "Zip Code:" & " " & request.form("ZipCode") & vbcrlf & "Telephone:" & " " & request.form("Phone") & vbcrlf & "Fax Number:" & " " & request.form("Fax") & vbcrlf & "Email:" & " " & request.form("Email") & vbcrlf & vbcrlf & "Type of Cancer" & " " & request.form("typeofCancer") & vbcrlf & vbcrlf & "on PregnantWithCancer.org. Login to approve or deny the request at http://www.pregnantwithcancer.org/restricted_access.shtml" & vbcrlf
myMail.Configuration.Fields.Item _ 
("http://schemas.microsoft.com/cdo/configuration/sendusing")=2 
'Name or IP of remote SMTP server 
myMail.Configuration.Fields.Item _ 
("http://schemas.microsoft.com/cdo/configuration/smtpserver") _ 
="mail.pregnantwithcancer.org" 
'Server port 
myMail.Configuration.Fields.Item _ 
("http://schemas.microsoft.com/cdo/configuration/smtpserverport") _ 
=25 
myMail.Configuration.Fields.Update 
myMail.Send 
set myMail=nothing 

    ' append the query string to the redirect URL
    Dim MM_editRedirectUrl
    MM_editRedirectUrl = "Thankyou.asp"
    If (Request.QueryString <> "") Then
      If (InStr(1, MM_editRedirectUrl, "?", vbTextCompare) = 0) Then
        MM_editRedirectUrl = MM_editRedirectUrl & "?" & Request.QueryString
      Else
        MM_editRedirectUrl = MM_editRedirectUrl & "&" & Request.QueryString
      End If
    End If
    Response.Redirect(MM_editRedirectUrl)
  End If
End If
%>
<%
Dim Recordset1
Dim Recordset1_cmd
Dim Recordset1_numRows

Set Recordset1_cmd = Server.CreateObject ("ADODB.Command")
Recordset1_cmd.ActiveConnection = MM_pwcn_database_STRING
Recordset1_cmd.CommandText = "SELECT * FROM tblStates ORDER BY [State] ASC" 
Recordset1_cmd.Prepared = true

Set Recordset1 = Recordset1_cmd.Execute
Recordset1_numRows = 0
%>
<%
Dim Country
Dim Country_cmd
Dim Country_numRows

Set Country_cmd = Server.CreateObject ("ADODB.Command")
Country_cmd.ActiveConnection = MM_pwcn_database_STRING
Country_cmd.CommandText = "SELECT * FROM tblCountries ORDER BY Country ASC" 
Country_cmd.Prepared = true

Set Country = Country_cmd.Execute
Country_numRows = 0
%>
<%
Dim TypeofBC
Dim TypeofBC_cmd
Dim TypeofBC_numRows

Set TypeofBC_cmd = Server.CreateObject ("ADODB.Command")
TypeofBC_cmd.ActiveConnection = MM_pwcn_database_STRING
TypeofBC_cmd.CommandText = "SELECT * FROM tblTypeofBC ORDER BY TypeofBC ASC" 
TypeofBC_cmd.Prepared = true

Set TypeofBC = TypeofBC_cmd.Execute
TypeofBC_numRows = 0
%>
<%
Dim CancerTypes
Dim CancerTypes_cmd
Dim CancerTypes_numRows

Set CancerTypes_cmd = Server.CreateObject ("ADODB.Command")
CancerTypes_cmd.ActiveConnection = MM_pwcn_database_STRING
CancerTypes_cmd.CommandText = "SELECT * FROM tblTypeofCancer ORDER BY TypeofCancer ASC" 
CancerTypes_cmd.Prepared = true

Set CancerTypes = CancerTypes_cmd.Execute
CancerTypes_numRows = 0
%>
<%
Dim TypeOfTreatment
Dim TypeOfTreatment_cmd
Dim TypeOfTreatment_numRows

Set TypeOfTreatment_cmd = Server.CreateObject ("ADODB.Command")
TypeOfTreatment_cmd.ActiveConnection = MM_pwcn_database_STRING
TypeOfTreatment_cmd.CommandText = "SELECT * FROM tblTreatmentTypes ORDER BY TreatmentType ASC" 
TypeOfTreatment_cmd.Prepared = true

Set TypeOfTreatment = TypeOfTreatment_cmd.Execute
TypeOfTreatment_numRows = 0
%>

<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>


<title>Volunteer Request | Become a Support Woman</title>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />
<meta name="Description" content="Become a Support Women and help women who are pregnant with cancer." />
<meta name="Keywords" content="Pregnant, Support Women, Cancer, Support, Pregnancy and Cancer, Pregnant with Cancer, Support Network, Pregnant support, Cancer Support, diagnosed, cancer during pregnancy, free support for women diagnosed with cancer, survivor stories, cancer survivor" />


<link href="styles/forms.css" rel="stylesheet" type="text/css" />
<script type="text/javascript">
<!--
function MM_validateForm() { //v4.0
  if (document.getElementById){
    var i,p,q,nm,test,num,min,max,errors='',args=MM_validateForm.arguments;
    for (i=0; i<(args.length-2); i+=3) { test=args[i+2]; val=document.getElementById(args[i]);
      if (val) { nm=val.name; if ((val=val.value)!="") {
        if (test.indexOf('isEmail')!=-1) { p=val.indexOf('@');
          if (p<1 || p==(val.length-1)) errors+='- '+nm+' must contain an e-mail address.\n';
        } else if (test!='R') { num = parseFloat(val);
          if (isNaN(val)) errors+='- '+nm+' must contain a number.\n';
          if (test.indexOf('inRange') != -1) { p=test.indexOf(':');
            min=test.substring(8,p); max=test.substring(p+1);
            if (num<min || max<num) errors+='- '+nm+' must contain a number between '+min+' and '+max+'.\n';
      } } } else if (test.charAt(0) == 'R') errors += '- '+nm+' is required.\n'; }
    } if (errors) alert('The following error(s) occurred:\n'+errors);
    document.MM_returnValue = (errors == '');
} }
//-->
</script>
</head>
<body style="">

<!-- DO NOT MOVE! The following AllWebMenus code must always be placed right AFTER the BODY tag-->
<!-- ******** BEGIN ALLWEBMENUS CODE FOR menu ******** -->
<script type='text/javascript'>var MenuLinkedBy='AllWebMenus [4]',awmMenuName='menu',awmBN='DW';awmAltUrl='';</script>
<script charset='UTF-8' src='menu.js' type='text/javascript'></script>
<script type='text/javascript'>awmBuildMenu();</script>
<!-- ******** END ALLWEBMENUS CODE FOR menu ******** -->
<!-- ImageReady Slices (page_template.pdf) -->
<div id="Table_01">
  <div id="index-01_">
    <img src="images/Hfor2_01.jpg" alt="" name="index_01" width="955" height="146" id="index_01" />
    <div id="header_menu"><a href="http://www.pregnantwithcancer.org">Home</a> | <a href="#">Contact
          Us</a> | <a href="our_glossary.php"> Our Glossary </a></div>
  </div>
  <div id="index-02_"><span id='awmAnchor-menu'>&nbsp;</span></div>
  <div id="index-04_">
    <div id="left_column">
      
      <p align="left" class="titles">Support Woman Information Form</p>
      <p align="left" class="Sub_Titles">Please Read First:</p>
      <p>Hope for Two...The Pregnant with
        Cancer Network is a national non-profit organization
        for women diagnosed with cancer during pregnancy.&nbsp; 
        Our mission is to connect women who are pregnant with cancer with other
        women who have been pregnant with the same type of cancer.&nbsp; These
        women are here to lend support, offer hope and share their experiences
      with one another through phone and e-mail conversation.</p>
      <p class="Sub_Titles">If you are interested in becoming a support woman please fill out the information below.      </p>
      <p> If you have previously been pregnant with cancer and would like to be a support woman in the future, please fill out our contact form below. To be a support woman, you would agree to speak with a pregnant woman, newly diagnosed with the same type of cancer that you had while pregnant. Women typically speak by phone or through email. You would share your experience to offer hope and support during this time. </p>
      <p><strong>NOTE: Fields marked with *   are required. If unsure of answer, please indicate so.</strong></p>
      <form id="form1" name="form1" method="POST" action="<%=MM_editAction%>">
        <table align="left">
          <tr valign="baseline">
            <td width="5%" align="right" nowrap="nowrap" class="form_field_text"><div align="left">First
                Name:</div></td>
            <td><input name="FirstName" type="text" id="FirstName" value="" size="32" /> <strong>*</strong> </td>
          </tr>
          <tr valign="baseline">
            <td width="5%" align="right" nowrap="nowrap" class="form_field_text"><div align="left">Last
                Name:</div></td>
            <td><input name="LastName" type="text" id="LastName" value="" size="32" /> <strong>*</strong> </td>
          </tr>
          <tr valign="baseline">
            <td width="5%" align="right" nowrap="nowrap" class="form_field_text"><div align="left">Street
                Address:</div></td>
            <td><input name="Address1" type="text" id="Address1" value="" size="32" /> <strong>*</strong> </td>
          </tr>
          <tr valign="baseline">
            <td width="5%" align="right" nowrap="nowrap" class="form_field_text"><div align="left"></div></td>
            <td><input type="text" name="Address2" value="" size="32" />            </td>
          </tr>
          <tr valign="baseline">
            <td width="5%" align="right" nowrap="nowrap" class="form_field_text"><div align="left">City:</div></td>
            <td><input name="City" type="text" id="City" value="" size="32" /> <strong>*</strong> </td>
          </tr>
          <tr valign="baseline">
            <td width="5%" align="right" nowrap="nowrap" class="form_field_text"><div align="left">State:</div></td>
            <td><select name="State" id="State">
              <option value="-- Select State --">-- Select State --</option>
              <%
While (NOT Recordset1.EOF)
%>
              <option value="<%=(Recordset1.Fields.Item("State").Value)%>"><%=(Recordset1.Fields.Item("State").Value)%></option>
              <%
  Recordset1.MoveNext()
Wend
If (Recordset1.CursorType > 0) Then
  Recordset1.MoveFirst
Else
  Recordset1.Requery
End If
%>
            </select> <strong>*</strong></td>
          </tr>
          <tr valign="baseline">
            <td width="5%" align="right" nowrap="nowrap" class="form_field_text"><div align="left">Zip
                Code:</div></td>
            <td><input name="ZipCode" type="text" id="ZipCode" value="" size="32" /> <strong>*</strong> </td>
          </tr>
          <tr valign="baseline">
            <td width="5%" align="right" nowrap="nowrap" class="form_field_text"><div align="left">Country:</div></td>
            <td><select name="Country" id="Country">
              <option value="-- Select Country --">-- Select Country --</option>
              <%
While (NOT Country.EOF)
%>
              <option value="<%=(Country.Fields.Item("Country").Value)%>"><%=(Country.Fields.Item("Country").Value)%></option>
              <%
  Country.MoveNext()
Wend
If (Country.CursorType > 0) Then
  Country.MoveFirst
Else
  Country.Requery
End If
%>
            </select> <strong>*</strong></td>
          </tr>
          <tr valign="baseline">
            <td width="5%" rowspan="5" align="right" nowrap="nowrap" class="form_field_text"><div align="left">If
                outside US, please <br />
              type entire address as it <br />
              should appear on <br />
              envelope:</div>
                <div align="left"></div>
              <div align="left"></div>
              <div align="left"></div>
              <div align="left"></div></td>
            <td>Line 1:
            <input type="text" name="OutsideUSAddress1" value="" size="32" />            </td></tr>
          <tr valign="baseline">
            <td>Line 2:
            <input type="text" name="OutsideUSAddress2" value="" size="32" />            </td></tr>
          <tr valign="baseline">
            <td>Line 3:
            <input type="text" name="OutsideUSAddress3" value="" size="32" />            </td></tr>
          <tr valign="baseline">
            <td>Line 4:
            <input type="text" name="OutsideUSAddress4" value="" size="32" />            </td></tr>
          <tr valign="baseline">
            <td>Line 5:
            <input type="text" name="OutsideUSAddress5" value="" size="32" />            </td></tr>
          <tr valign="baseline">
            <td width="5%" align="right" nowrap="nowrap" class="form_field_text"><div align="left">Phone:</div></td>
            <td><input type="text" name="Phone" value="" size="32" />
            <br />
            <strong>(Include Area Code) </strong> </td>
          </tr>
          <tr valign="baseline">
            <td width="5%" align="right" nowrap="nowrap" class="form_field_text"><div align="left">Best
                time to call:</div></td>
            <td><input type="text" name="TimetoContact" value="" size="32" />            </td>
          </tr>
          <tr valign="baseline">
            <td width="5%" align="right" nowrap="nowrap" class="form_field_text"><div align="left">Fax
                Number:</div></td>
            <td><input type="text" name="Fax" value="" size="32" />
            <br />
            <strong>(Include Area Code) </strong> </td>
          </tr>
          <tr valign="baseline">
            <td width="5%" align="right" nowrap="nowrap" class="form_field_text"><div align="left">Email
                Address:</div></td>
            <td><input type="text" name="Email" value="" size="32" />            </td>
          </tr>
          <tr valign="baseline">
            <td width="5%" align="right" nowrap="nowrap" class="form_field_text"><div align="left"><strong>Language:</strong></div></td>
            <td><input type="text" name="Language" value="" size="32" />            </td>
          </tr>
          <tr valign="baseline">
            <td width="5%" align="right" nowrap="nowrap" class="form_field_text"><div align="left">Preferred
                method of contact:</div></td>
            <td><select name="Methodofcontact" id="Methodofcontact">
                <option value="-- Select One --">-- Select One -- </option>
                <option value="Phone">Phone</option>
                <option value="Email">Email</option>
                <option value="Either">Either</option>
            </select></td>
          </tr>
          <tr valign="baseline">
            <td width="5%" align="right" valign="top" nowrap="nowrap" class="form_field_text"><div align="left">Type
                of Cancer:</div></td>
            <td><select name="TypeofCancer" size="7" multiple="multiple" id="TypeofCancer">
              <%
While (NOT CancerTypes.EOF)
%>
              <option value="<%=(CancerTypes.Fields.Item("TypeofCancer").Value)%>"><%=(CancerTypes.Fields.Item("TypeofCancer").Value)%></option>
              <%
  CancerTypes.MoveNext()
Wend
If (CancerTypes.CursorType > 0) Then
  CancerTypes.MoveFirst
Else
  CancerTypes.Requery
End If
%>
                        </select>               *</td>
          </tr>
          <tr valign="baseline">
            <td width="5%" align="right" nowrap="nowrap" class="form_field_text"><div align="left">What
                stage is the cancer?</div></td>
            <td><input type="text" name="StageofCancer" value="" size="32" />            </td>
          </tr>
          <tr valign="baseline">
            <td width="5%" align="right" nowrap="nowrap" class="form_field_text"><div align="left">If
                Breast Cancer, what type?</div></td>
            <td><select name="TypeofBreastCancer" id="TypeofBreastCancer">
              <option value="">Select Type of Breast Cancer</option>
              <%
While (NOT TypeofBC.EOF)
%>
              <option value="<%=(TypeofBC.Fields.Item("TypeofBC").Value)%>"><%=(TypeofBC.Fields.Item("TypeofBC").Value)%></option>
              <%
  TypeofBC.MoveNext()
Wend
If (TypeofBC.CursorType > 0) Then
  TypeofBC.MoveFirst
Else
  TypeofBC.Requery
End If
%>
            </select></td>
          </tr>
          <tr valign="baseline">
            <td width="5%" align="right" nowrap="nowrap" class="form_field_text"><div align="left">Date
                Diagnosed:</div></td>
            <td><input name="DateDiagnosed" type="text" id="DateDiagnosed" value="" size="32" />
              <span class="form_field_text">*<br />
              <strong>(Must at least have the 4 digit year entered - <br />
Format: yyyy-mm-dd) </strong> </span></td>
          </tr>
          <tr valign="baseline">
            <td width="5%" align="right" nowrap="nowrap" class="form_field_text"><div align="left">Number
                of weeks pregnant when diagnosed: </div></td>
            <td><input name="WeeksPreg" type="text" id="WeeksPreg" value="" size="32" />              
            *                        </td>
          </tr>
          <tr valign="baseline">
            <td width="5%" align="right" nowrap="nowrap" class="form_field_text"><div align="left">Type
                of surgery you had / was recommended:</div></td>
            <td><input type="text" name="Surgery" value="" size="32" />            </td>
          </tr>
          <tr valign="baseline">
            <td colspan="2" align="right" nowrap="nowrap"><div align="left">Type
                of therapy/treatment you had:<br />
                    <select name="TypeofTreatment" size="10" multiple="multiple" class="form_field_text" id="TypeofTreatment">
                      <option value="">Select Cancer Types</option>
                      <%
While (NOT TypeOfTreatment.EOF)
%>
                      <option value="<%=(TypeOfTreatment.Fields.Item("TreatmentType").Value)%>"><%=(TypeOfTreatment.Fields.Item("TreatmentType").Value)%></option>
                      <%
  TypeOfTreatment.MoveNext()
Wend
If (TypeOfTreatment.CursorType > 0) Then
  TypeOfTreatment.MoveFirst
Else
  TypeOfTreatment.Requery
End If
%>
                    </select>
            *</div></td>
          </tr>
          <tr valign="baseline">
            <td nowrap="nowrap" align="right"><div align="left">If your therapy/treatment is<br />
            not listed above please enter it here:</div></td>
            <td><input type="text" name="OtherTreatment" value="" size="32" />            </td>
          </tr>
          <tr valign="baseline">
            <td nowrap="nowrap" align="right"><div align="left">Your age at diagnosis: </div></td>
            <td><input name="AgeatDiagnosed" type="text" id="AgeatDiagnosed" value="" size="32" />              
            *            </td>
          </tr>
          <tr valign="baseline">
            <td colspan="2" align="right" nowrap="nowrap"><div align="left">
                <input type="checkbox" name="SpeakingwSW" value="1" />
              Yes, I am interested in speaking with a support woman, please contact
            me. </div></td>
          </tr>
          <tr valign="baseline">
            <td colspan="2" align="right" nowrap="nowrap"><div align="left">
                <input type="checkbox" name="ContactwSW" value="1" />
            Please connect me with a support woman, whom I will contact. </div></td>
          </tr>
          <tr valign="baseline">
            <td colspan="2" align="right" nowrap="nowrap"><div align="left">
              <input type="checkbox" name="SendMail" value="1" />
            Please add my name to the&nbsp; mailing list to receive your newsletter. </div></td>
          </tr>
          <tr valign="baseline">
            <td colspan="2" align="right" nowrap="nowrap"><div align="left">
                <input type="checkbox" name="SendInfoPkg" value="1" />
            Please send me a PWCN packet of information. </div></td>
          </tr>
          <tr valign="baseline">
            <td nowrap="nowrap" align="right">&nbsp;</td>
            <td>&nbsp;</td>
          </tr>
          <tr valign="baseline">
            <td colspan="2" align="right" nowrap="nowrap"><div align="left"><span class="Sub_Titles">If you have another
              type of request, please describe it in the explanation section
              below. </span><br />
            Detailed explanation of request (if required):</div></td>
          </tr>
          <tr valign="baseline">
            <td colspan="2" align="right" nowrap="nowrap"><div align="left">
              <textarea name="DetailedRequest" cols="45" rows="6"></textarea>            
            </div></td>
          </tr>
          <tr valign="baseline">
            <td nowrap="nowrap" align="right">&nbsp;</td>
            <td>&nbsp;</td>
          </tr>
          <tr valign="baseline">
            <td colspan="2" align="right" nowrap="nowrap"><div align="left"><span class="Sub_Titles">Your Questions or Feedback</span><br />
            Please enter your questions or feedback in the field below.</div></td>
          </tr>
          <tr valign="baseline">
            <td colspan="2" align="right" nowrap="nowrap"><div align="left">
              <textarea name="Feedback" cols="45" rows="6"></textarea>            
            </div></td>
          </tr>
          
          <tr valign="baseline">
            <td nowrap="nowrap" align="right"><div align="left">How did you hear about us?</div></td>
            <td><input type="text" name="HowFoundPWCN" value="" size="32" />            </td>
          </tr>
          <tr valign="baseline">
            <td nowrap="nowrap" align="right"><div align="left">If other, please specify:</div></td>
            <td><input type="text" name="OtherHowFound" value="" size="32" />            </td>
          </tr>
          <tr valign="baseline">
            <td colspan="2" align="right" nowrap="nowrap"><div align="left">
                <input type="checkbox" name="InterestedSW" value="1" />
            I would be interested in becoming a support woman in the future. </div></td>
          </tr>
          <tr valign="baseline">
            <td colspan="2" align="right" nowrap="nowrap"><div align="left">
              <input type="submit" onclick="MM_validateForm('FirstName','','R','LastName','','R','Address1','','R','City','','R','ZipCode','','R','DateDiagnosed','','R','WeeksPreg','','R','AgeatDiagnosed','','R');return document.MM_returnValue" value="Submit Your Information" />            
              <br />
              <div align="left"><br />
              </div>
              <div align="left"><em><strong>The content of form submissions and
                    email messages will be treated as personal and private <br />
                correspondence and will not be published or distributed in any
                way.</strong></em></div>
            </div></td>
          </tr>
        </table>
            
        <input type="hidden" name="MM_insert" value="form1" />
</form>
      <p>&nbsp;</p>
      <p>&nbsp;</p>
      <p class="titles">&nbsp;</p>
      </div>
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