<% SendEmailTo = "pacenyemail@aol.com" Subject = Request("Subject") FromEmail = Request("Email_Address") FromName = Request("Full_Name") %> epilepsytalk <% If Request("submitted") = "1" Then %> <% Mail.IsHTML = True Mail.Host = "smtp.dataholdings.net" Mail.AddAddress SendEmailTo Mail.From = FromEmail Mail.FromName = FromName Mail.Subject = Subject Mail.Body = ""_ & "
Full Name: " & Request("Full_Name")_ & "
Mailing Address: " & Request("Mailing_Address")_ & "
City: " & Request("City")_ & "
State: " & Request("State")_ & "
Zip: " & Request("Zip")_ & "
Country: " & Request("Country")_ & "
Phone: " & Request("Phone")_ & "
Email Address: " & Request("Email_Address")_ & "
" & Request("Fax")_ & "
Child's Name: " & Request("Childs_Name")_ & "
Age: " & Request("Age")_ & "
Sex: " & Request("Sex")_ & "
Type of Seizure: " & Request("Seizure")_ & "
Frequency: " & Request("Frequency")_ & "
Medications: " & Request("Med")_ & "
Doctor: " & Request("Dr")_ & "
Hospital: " & Request("Hospital")_ & "
Diagnosis: " & Request("Diagnosis")_ & "" On Error Resume Next if not Mail.Send Then ErrStr = Err.Description Else arrTo.RemoveAll arrCc.RemoveAll arrBcc.RemoveAll arrFiles.RemoveAll End If On Error Goto 0 %>
epilepsytalk
Thank you <%=Request("Full_Name")%>.

You have successfully submitted your application to join Epilepsytalk. Soon you should receive an email from asking you to confirm that you would like to join. Please reply without changing the email. Then you will receive an email with instructions telling you where to send your messages to the rest of the group.

Thanks again.



<% Else %>
epilepsytalk
New Members Registration

Are you concerned about: seizure disorders, Rett syndrome, infantile spasms, ketogenic diet, AED, new drugs, clinical trials, EEG's, spinal taps, pediatric epilepsy, surgery, homeopathy, naturopathy, osteopathy or Chinese medicine?

Required information is marked with an asterisk (*).

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Full Name*:Mailing Address:
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