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<FORM NAME="RegistrationForm" METHOD="POST" ACTION="index.cfm?module=Training&amp;option=ProcessClassRegistration&amp;ClassID=1271">

<INPUT type="hidden" name="UserID" value="">


<table class="ClassForm" cellpadding="8" cellspacing="0" width="95%" align="center" cols="2" summary="Training Registration">

					<tr>
					<td class="ClassListTitleText" align="left" valign="top" width="50%">Please fill out all form fields.
					</td>
					<td class="ClassListTitleText" align="left" valign="top" width="50%">
					</td>
					</tr>
					
					<tr>
					<td class="ClassListTitleText" align="left" id="C1" valign="top" width="50%"><label for="UserFirstName">First Name:</label>
					<br>
					<INPUT TYPE="TEXT" style="width:100%;background:#FDFDE6" NAME="UserFirstName" size="2" width="40" class="ClassListRegularText" value="" id="UserFirstName">
					</td>
					
					<td class="ClassListTitleText" align="left" id="C2" valign="top"><label for="UserLastName">Last Name:</label>
					<br>
					<INPUT TYPE="TEXT" style="width:97%;background:#FDFDE6" NAME="UserLastName" size="2" width="40" class="ClassListRegularText" value="" id="UserLastName">
					</td>
					</tr>
										
					<tr>					
					<td class="ClassListTitleText" align="left" id="C3" valign="top"><label for="UserEmail">Email Address:</label>
					<br>
					<INPUT TYPE="TEXT" style="width:100%;background:#FDFDE6" NAME="UserEmail" size="2" width="40" class="ClassListRegularText" value="" id="UserEmail">
					</td>

					<td class="ClassListTitleText" align="left" id="C4" valign="top">
					<label for="UserPhone">Phone Number (digits only):</label>
					<br>
					<INPUT TYPE="TEXT" style="width:100px;background:#FDFDE6" NAME="UserPhone" size="2" width="40" class="ClassListRegularText" value="" id="UserPhone">
					</td>
					</tr>		
					
					<tr>					
					<td class="ClassListTitleText" align="left" id="C3" valign="top"><label for="UserJobTitle">Job Title:</label>
					<br>
					<INPUT TYPE="TEXT" style="width:100%;background:#FDFDE6" NAME="UserJobTitle" size="2" width="40" class="ClassListRegularText" value="" id="UserJobTitle">
					</td>

					<td class="ClassListTitleText" align="left" id="C4" valign="top">
					<label for="UserDepartment">Department:</label>
					<br>
					<INPUT TYPE="TEXT" style="width:97%;background:#FDFDE6" NAME="UserDepartment" size="2" width="40" class="ClassListRegularText" value="" id="UserDepartment">
					</td>
					</tr>	
					
					<tr>					
					<td class="ClassListTitleText" align="left" id="C3" valign="top"><label for="UserArea">Your Area:</label>
					<br>
						

						<select name="UserArea" style="width:100%;background:#FDFDE6" SIZE="1" class="ClassListRegularText" id="UserArea">
									
										<option id="UserArea" value="None Selected" class="ClassListRegularText" selected>None Selected</option>
									
										<option id="UserArea" value="1" class="ClassListRegularText">Aberdeen</option>
										
									
										<option id="UserArea" value="2" class="ClassListRegularText">Alaska</option>
										
									
										<option id="UserArea" value="3" class="ClassListRegularText">Albuquerque</option>
										
									
										<option id="UserArea" value="4" class="ClassListRegularText">Bemidji</option>
										
									
										<option id="UserArea" value="5" class="ClassListRegularText">Billings</option>
										
									
										<option id="UserArea" value="6" class="ClassListRegularText">California</option>
										
									
										<option id="UserArea" value="13" class="ClassListRegularText">Headquarters</option>
										
									
										<option id="UserArea" value="7" class="ClassListRegularText">Nashville</option>
										
									
										<option id="UserArea" value="8" class="ClassListRegularText">Navajo</option>
										
									
										<option id="UserArea" value="14" class="ClassListRegularText">NP/OIT</option>
										
									
										<option id="UserArea" value="9" class="ClassListRegularText">Oklahoma</option>
										
									
										<option id="UserArea" value="10" class="ClassListRegularText">Phoenix</option>
										
									
										<option id="UserArea" value="11" class="ClassListRegularText">Portland</option>
										
									
										<option id="UserArea" value="12" class="ClassListRegularText">Tucson</option>
										
									
								</select>
					</td>

					<td class="ClassListTitleText" align="left" id="C4" valign="top">
					<label for="UserSite">Your Site:</label>
					<br>
					<INPUT TYPE="TEXT" style="width:97%;background:#FDFDE6" NAME="UserSite" size="2" width="40" class="ClassListRegularText" value="" id="UserSite">
					</td>
					</tr>
	
																	
					<tr>
					<td class="ClassListTitleText" align="left" id="C4a" valign="bottom" colspan="2">
					Does your facility currently use this RPMS application?
				<br><span class="ClassListRegularText">
					<label for="Yes2">Yes</label><input type="Radio" name="UserUseApp" value="Yes" id="Yes2">&nbsp;&nbsp;&nbsp;<label for="No2">No</label><input type="Radio" name="UserUseApp" value="No" id="No2" checked>&nbsp;</span><br>

					</td>
					</tr>
					
					<tr>
					<td class="ClassListTitleText" align="left" id="C4" valign="bottom" colspan="2">
					<label for="UserRPMSExperience">Describe your experience with this topic/application and other RPMS applications:</label>
					<br>
					<textarea style="width:99%;height:50px;background:#FDFDE6" name="UserRPMSExperience" id="UserRPMSExperience" class="ClassListRegularText"></textarea><br>
					</td>
					</tr>
					

					<tr>
					<td class="ClassListTitleText" align="left" id="C4" valign="bottom" colspan="2">
					Accessibility Accommodations that you need to have met:
					<br>		
				<span STYLE="white-space: nowrap" class="ClassListRegularText">

<label for="1">None</label><input type="Checkbox" name="UserSpecialNeeds" value="1" id="1">
</span>  <span STYLE="white-space: nowrap" class="ClassListRegularText">

<label for="2">Large Print</label><input type="Checkbox" name="UserSpecialNeeds" value="2" id="2">
</span>  <span STYLE="white-space: nowrap" class="ClassListRegularText">

<label for="3">Braille</label><input type="Checkbox" name="UserSpecialNeeds" value="3" id="3">
</span>  <span STYLE="white-space: nowrap" class="ClassListRegularText">

<label for="4">Portable Media</label><input type="Checkbox" name="UserSpecialNeeds" value="4" id="4">
</span>  <span STYLE="white-space: nowrap" class="ClassListRegularText">

<label for="5">Assistive Listening Technology</label><input type="Checkbox" name="UserSpecialNeeds" value="5" id="5">
</span>  <span STYLE="white-space: nowrap" class="ClassListRegularText">

<label for="6">Sign Language Interpreter</label><input type="Checkbox" name="UserSpecialNeeds" value="6" id="6">
</span>  <span STYLE="white-space: nowrap" class="ClassListRegularText">

<label for="7">CART</label><input type="Checkbox" name="UserSpecialNeeds" value="7" id="7">
</span>  <span STYLE="white-space: nowrap" class="ClassListRegularText">

<label for="8">Other</label><input type="Checkbox" name="UserSpecialNeeds" value="8" id="8">
</span>  		 

					</td>
					</tr>

					<tr>
					<td class="ClassListTitleText" align="left" id="C4" valign="bottom" colspan="2">
					<label for="UserOtherSpecialNeeds">Other Accessibility Accommodations that you need to have met:</label>
					<br>
					<textarea style="width:99%;height:50px;background:#FDFDE6" name="UserOtherSpecialNeeds" class="ClassListRegularText" id="UserOtherSpecialNeeds"></textarea>
					</td>
					</tr>					
				
					<tr>
					<td class="ClassListTitleText" align="center" id="C9" valign="top" colspan="3">
					<INPUT type="submit" style="width:40%;height:40px;background:#EEEEA2;border-color:3px solid #FFFFDC #C3C37A  #C3C37A #FFFFDC" NAME="Submit" alt="Register for This Class" value="Register for This Class" class="ClassListTitleText">
					</td>					
					</tr>
				
					<tr>
					<td class="ClassListTitleText" align="center" id="C10" valign="top" colspan="6">
					<a href="index.cfm?module=Training&amp;option=Index&amp;sortChoice=Title&amp;rowStart=1" class="ClassListRegularText"><<< Return to Class List</A>
					</td>					
					</tr>				
				
					<tr>
					<td class="ClassListTitleText" align="center" id="C10" valign="top" colspan="6">
					<a href="index.cfm?module=Training&amp;option=ClassDetail&amp;ClassID=1271" class="ClassListRegularText"><<< Return to Class</A>
					</td>					
					</tr>
										
								
</table>

</FORM>


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