| Current File : /home/inlingua/public_html/sensoriumpsychologists.com/screening-registration_old.php |
<?php
session_start();
include('include/header.php');
include_once('classes/config.php');
//
if(isset($_SESSION['c_error']) && $_SESSION['c_error']==1)
{
$Caperror='<span style="color:red;">reCAPTCHA is mandatory</span>';
}else{
$Caperror='';
}
?>
<div class="site-breadcrumb">
<div class="container">
<a href="index.php"><i class="fa fa-home"></i> Home</a> <i class="fa fa-angle-right"></i>
<span>Registration</span><i class="fa fa-angle-right"></i>
<span>Screening Registration</span>
</div>
</div>
<section class="event-section">
<div class="container">
<div class="section-title text-center">
<h3>Register for Screening </h3>
<p>When a learning difficulty is suspected in a child, screenings are highly recommended. Screenings can be short and online assessment tool that can indicate the level of risk and also can recommend for further comprehensive testing if required.
If dyslexia, dysgraphia, ADHD or dyscalculia are suspected, comprehensive testing can be performed by a certified psychologist.</p><p>
This is must to understand that two people with a learning difficulty/disability struggle with the same set or severity of symptoms and thus it’s important to understand where strengths and areas of need lie in order to provide the best strategy training and accommodations.
</p>
</div>
</div>
</section>
<section class="contact-page spad pt-0">
<div class="container">
<div class="text-center">
<h3><?php echo $Caperror; ?></h3>
<p></p>
</div>
<style>
#reg table {
border: 0px solid #ccc;
width: 100%;
}
#reg table tr{
border: 0px;
padding:0px;
}
#reg table td{
border: 0px;
padding:0px;
}
</style>
<div class="sc_contact_form sc_contact_form_contact contact-form" style="border:1px solid #c3c3cc; padding:25px;" id="reg">
<form method="post" action="diagnostics/franchise/new-admission.php" class="validate123 comment-form --contact" name="txnSubmitFrm" id="txnSubmitFrm" enctype="multipart/form-data" novalidate="novalidate" >
<?php
$today = date("ymd");
$rand = strtoupper(substr(uniqid(sha1(time())),0,4));
$unique1 = $today . $rand;?>
<input type="hidden" name="registration_no" value="<?php echo "SU".$unique1;?>" >
<!--<form method="post" name="myform" enctype="multipart/form-data">-->
<table >
<tr>
<td style="font-weight:bold;">Student's Name<span style="color:#F00;font-weight:bold;font-size:17px;">*</span>:</td>
<td><input type="text" name="child_name" id="child_name" /></td>
<td style="font-weight:bold;width:120px;">Email<span style="color:#F00;font-weight:bold;font-size:17px;">*</span>:</td>
<td><input type="text" name="email" id="email" /></td>
</tr>
<tr>
<td style="font-weight:bold;width:120px;">Age<span style="color:#F00;font-weight:bold;font-size:17px;">*</span>:</td>
<td><select name="age" id="age">
<option value="">---Years---</option>
<option>5</option>
<option>6</option>
<option>7</option>
<option>8</option>
<option>9</option>
<option>10</option>
<option>11</option>
<option>12</option>
<option>13</option>
<option>14</option>
<option>15</option>
</select>
</td>
<td style="font-weight:bold;width:120px;">Gender<span style="color:#F00;font-weight:bold;font-size:17px;">*</span>:</td>
<td><select name="gender" id="gender">
<option value="">---Gender---</option>
<option>Male</option>
<option>Female</option>
</select></td>
</tr>
<tr>
<td style="font-weight:bold;">Date of Birth<span style="color:#F00;font-weight:bold;font-size:17px;">*</span>:</td>
<td><select name="dob_day" id="dob_day" style="width:30%;">
<option value="">---Date---</option>
<?php
for($i=1;$i<=31;$i++)
{
echo("<option>".$i."</option>");
}
?>
</select>
<select name="dob_month" id="dob_month" style="width:30%;">
<option value="">---Month---</option>
<option value="01">Jan</option>
<option value="02">Feb</option>
<option value="03">Mar</option>
<option value="04">Apr</option>
<option value="05">May</option>
<option value="06">Jun</option>
<option value="07">Jul</option>
<option value="08">Aug</option>
<option value="09">Sep</option>
<option value="10">Oct</option>
<option value="11">Nov</option>
<option value="12">Dec</option>
</select>
<select name="dob_year" id="dob_year" style="width:30%;">
<option value="">---Year---</option>
<?php
$year=date("Y");
$i=$year-15;
for(;$i<=$year;$i++)
{
echo("<option>".$i."</option>");
}
?>
</select></td>
<td style="font-weight:bold;">Education<span style="color:#F00;font-weight:bold;font-size:17px;">*</span>:</td>
<td><select name="education" id="education">
<option value="">---std---</option>
<option value="1">1st</option>
<option value="2">2nd</option>
<option value="3">3rd</option>
<option value="4">4th</option>
<option value="5">5th</option>
<option value="6">6th</option>
<option value="7">7th</option>
<option value="8">8th</option>
<option value="9">9th</option>
<option value="10">10th</option>
</select>
</td>
</tr>
<tr>
<td style="font-weight:bold;width:120px;">School Name<span style="color:#F00;font-weight:bold;font-size:17px;">*</span>:</td>
<td><input type="text" name="school_name" id="school_name" /></td>
<td style="font-weight:bold;">Contact No<span style="color:#F00;font-weight:bold;font-size:17px;">*</span>:</td>
<td><input type="text" name="contact_no" id="contact_no" /></td>
</tr>
<tr>
<td style="font-weight:bold;">Informant<span style="color:#F00;font-weight:bold;font-size:17px;">*</span>:</td>
<td><input type="text" name="informant" id="informant" /></td>
</tr>
<tr><td></td>
<td><div class="site-btn" value="Save" onClick="submit_form();" />
Save
</div>
</td>
</tr>
</table>
</form>
</div>
</div>
</section>
<script type="text/javascript">
function submit_form()
{
if($("#child_name").val()=="")
{
alert("Error : Please enter Student's name...");
$("#child_name").focus();
return false;
}
if($("#email").val()=="")
{
alert("Error : Please enter Email...");
$("#email").focus();
return false;
}
if($("#age").val()=="")
{
alert("Error : Please select Student's age...");
$("#age").focus();
return false;
}
if($("#gender").val()=="")
{
alert("Error : Please select gender");
$("#gender").focus();
return false;
}
if($("#dob_day").val()=="")
{
alert("Error : Please select Day in D.O.B");
$("#dob_day").focus();
return false;
}
if($("#dob_month").val()=="")
{
alert("Error : Please select Month in D.O.B");
$("#dob_month").focus();
return false;
}
if($("#dob_year").val()=="")
{
alert("Error : Please select Year in D.O.B");
$("#dob_year").focus();
return false;
}
if($("#education").val()=="")
{
alert("Error : Please select Education");
$("#education").focus();
return false;
}
if($("#school_name").val()=="")
{
alert("Error : Please enter school name");
$("#school_name").focus();
return false;
}
if($("#contact_no").val()=="")
{
alert("Error : Please select contact no");
$("#contact_no").focus();
return false;
}
if($("#informant").val()=="")
{
alert("Error : Please select informant");
$("#informant").focus();
return false;
}
var ans=confirm("Are you sure you want to continue?");
if(ans==true)
{
document.txnSubmitFrm.submit();
}
else
{
return false;
}
}
</script>
<?php include('include/footer.php'); ?>
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