My form worked before and now that I added the confirmation popup at the bottom, it no longer works. I don't know what is going on and I'm hoping getting a second set of eyes on this will reveal my mistake. Thank you in advance for looking at this!
<?php #Registration
//Arrays
$months = array('January', 'February', 'March', 'April', 'May', 'June', 'July', 'August', 'September', 'October', 'November', 'December');
$season = array('Fall 2014', 'Winter 2014', 'Spring 2015', 'Summer 2015');
$days = array('1', '2', '3', '4', '5', '6', '7', '8', '9', '10', '11', '12', '13', '14', '15', '16', '17', '18', '19', '20', '21', '22', '23', '24', '25', '26', '27', '28', '29', '30', '31');
$locations = array('Priest River', 'Sandpoint', 'Online');
function makeSafe($value) {
return stripslashes(trim($value));
}
//Form Subitted
if (!empty($_POST['submit'])) {
//form submitted through post, do validation
$authorization = (!empty($_POST['authorization'])) ? makeSafe($_POST['authorization']) : '';
$signature = (!empty($_POST['signature'])) ? makeSafe($_POST['signature']) : '';
$cc = makeSafe($_POST['cc']);
$ll = makeSafe($_POST['ll']);
$fname = makeSafe($_POST['fname']);
$mname = makeSafe($_POST['mname']);
$lname = makeSafe($_POST['lname']);
$pname = makeSafe($_POST['pname']);
$mm = makeSafe($_POST['mm']);
$dd = makeSafe($_POST['dd']);
$year = makeSafe($_POST['year']);
$age = makeSafe($_POST['age']);
$school = makeSafe($_POST['school']);
$address = makeSafe($_POST['address']);
$city = makeSafe($_POST['city']);
$state = makeSafe($_POST['state']);
$zip = makeSafe($_POST['zip']);
$gender = makeSafe($_POST['gender']);
$email = makeSafe($_POST['email']);
$phone = makeSafe($_POST['phone']);
$altph = makeSafe($_POST['altph']);
$sn = makeSafe($_POST['sn']);
$hp = makeSafe($_POST['hp']);
$packet = (!empty($_POST['signature'])) ? makeSafe($_POST['packet']) : '';
$message = '';
$problem = FALSE;
//Check Season Selected DropDown Array
if(isset($_POST['cc']) && !empty($_POST['cc']))
{
// if cc is in $season array
if(in_array($_POST['cc'], $season))
{
// this value is not accepted or "- Select Season -" selected
}
else
{
$seasonMessage .= '<p class="errorClass">Required</p>';
}
}
//Check Class Location Selected DropDown Array
if(isset($_POST['ll']) && !empty($_POST['ll']))
{
// if ll is in $locations array
if(in_array($_POST['ll'], $locations))
{
// this value is not accepted or "- Select Location -" selected
}
else
{
$locationMessage .= '<p class="errorClass">Required</p>';
}
}
//Check Birth Month Selected DropDown Array
if(isset($_POST['mm']) && !empty($_POST['mm']))
{
// if mm is in $months array
if(in_array($_POST['mm'], $months))
{
// this value is not accepted or "- Select Month -" selected
}
else
{
$monthMessage .= '<p class="errorClass">Required</p>';
}
}
//Check Birth Day Selected DropDown Array
if(isset($_POST['dd']) && !empty($_POST['dd']))
{
// if dd is in $day array
if(in_array($_POST['dd'], $days))
{
// this value is not accepted or "- Select Day -" selected
}
else
{
$dayMessage .= '<p class="errorClass">Required</p>';
}
}
//Check Gender
//if (empty($_POST["gender"])) {
//$genderMessage .= '<p class="errorClass">Required</p>';
//}
//Check Read Authorization
if($_POST['authorizaton']!="1" AND $_POST['packet']!="1"){
$problem = TRUE;
$parentMessage .= '<p class="errorClass parentMsg">Please read and check the boxes below.</p>';
}
//Check Electronic Signature
if($_POST['signature']!="1"){
$problem = TRUE;
$signatureMessage .= '<p class="errorClass">Required</p>';
}
//Check First Name
if (!eregi ('^[[:alpha:]\.\' \-]{2,}$',$fname)) {
$problem = TRUE;
$fnameMessage .= '<p class="errorClass">Required</p>';
}
//Check Last Name
if (!eregi ('^[[:alpha:]\.\' \-]{2,}$',$lname)) {
$problem = TRUE;
$lnameMessage .= '<p class="errorClass">Required</p>';
}
//Check Parent/Guardian Name
if (!eregi ('^[[:alpha:]\.\' \-\ ]{2,}$',$pname)) {
$problem = TRUE;
$pnameMessage .= '<p class="errorClass">Required</p>';
}
//Check School Name
if (!eregi ('^[[:alnum:]\.\' \-\,]{4,}$', $school)) {
$problem = TRUE;
$schoolMessage .= '<p class="errorClass">Required</p>';
}
//Check Student Address
if (!eregi ('^[[:alnum:]\.\' \#\-]{4,}$', $address)) {
$problem = TRUE;
$addyMessage .= '<p class="errorClass">Required</p>';
}
//Check City
if (!eregi ('^[[:alpha:]\.\' \-]{4,}$', $city)) {
$problem = TRUE;
$cityMessage .= '<p class="errorClass">Required</p>';
}
//Check State
if (!eregi ('^[[:alpha:]\.\' \-\ ]{2,2}$', $state)) {
$problem = TRUE;
$stateMessage .= '<p class="errorClass">Required</p>';
}
//Check Email
if (!eregi ('^[[:alnum:]][a-zA-Z0-9._-]+@[a-zA-Z0-9._-]+\.([a-zA-Z]{2,4})$',$email)) {
$problem = TRUE;
$emailMessage .= '<p class="errorClass">Required</p>';
}
//Check Zip
if (!eregi ('^[0-9]{5}(\-[0-9]{4})?$',$zip)) {
$problem = TRUE;
$zipMessage .= '<p class="errorClass">Required</p>';
}
//Check Phone
if (!eregi ('^[0-9.\(\)\-\ ]{10,14}$', $phone)) {
$problem = TRUE;
$phoneMessage .= '<p class="errorClass">Required</p>';
}
//Check Age
if(!eregi('^[0-9]{2}$',$age)) {
$problem = TRUE;
$ageMessage .= '<p class="errorClass">Required</p>';
}
//Check Year
if(!eregi('^[0-9]{2,4}$',$year)) {
$problem = TRUE;
$yearMessage .= '<p class="errorClass">Required</p>';
}
if ($problem == TRUE) {//Something went wrong
echo $message;
echo '';
}
else{
$to = "webangel119@yahoo.com";
$subject = "Buckle-Up New Student Registration for $fname $lname";
$headers = 'From: webangel119@yahoo.com' . "\r\n" .'X-Mailer: PHP/' . phpversion();
$msg .= "PLAIN TEXT EMAIL\n\n";
$msg .= "Location: $ll Class: $cc\n\n";
$msg .= "Name: $fname $mname $lname\n\n";
$msg .= "Parent/Guardian Name: $pname\n\n";
$msg .= "Birthday: $mm $day $year Age: $age Gender: $gender\n\n";
$msg .= "School: $school\n\n";
$msg .= "Address: $address\n\n";
$msg .= "City: $city State: $state Zip Code: $zip\n\n";
$msg .= "Phone: $phone Alternate Contact: $altph\n\n";
$msg .= "Email: $email\n\n";
$msg .= "Special Needs: $sn\n\n";
$msg .= "Health Problems or Allergies: $hp\n\n";
$msg .= "I Parent/Guardian understand the traffic safety education course consists of 30 clock-hours of classroom instruction, 6 hours of behind-the-wheel instruction and 6 hours of in-car observation. I also understand that instruction is provided by a properly certified instructor licensed by the Idaho Department of Education and the Idaho Bureau of Occupational Licenses, and the behind-the-wheel training takes place in a dual-control vehicle that is adequately insured. I accept the fact that the Buckle-UP Driving School, LLC will not be responsible for any driving the student may do outside the Driver Education program. In addition I acknowledge that portions of the student participation in this traffic safety education course may be videotaped for feedback and grading as well as for use in future training courses.\n\n";
$msg .= "I Parent/Guardian have read the student/parent or guardian information packet for Driver Education and hereby give approval for the above student to participate in the course.\n\n";
$msg .= "Parent/Guardian Authorized Signature: Electronically Signed\n\n";
if(mail($to, $subject, $msg, $headers) == false){
// Email failed
echo "<script type='text/javascript'>alert('failed!')</script>";
}
else {
echo
$authorization = '';
$ll = '';
$cc = '';
$fname = '';
$mname = '';
$lname = '';
$pname = '';
$mm = '';
$dd = '';
$year = '';
$age = '';
$school = '';
$address = '';
$city = '';
$state = '';
$zip = '';
$gender = '';
$email = '';
$phone = '';
$altph = '';
$hp = '';
$sn = '';
$signature = '';
$packet = '';
}
}
}
?>
HTML
<form id="registration" class="registrationSettings" name="registration" method="post" action="#" onsubmit="myFunction();return false")>
<div class="formHeading">DRIVER EDUCATION ENROLLMENT FORM</div>
<section>
<div class="fieldBox">
<div class="label"><p class="bold">Location</p></div>
<div class="field"><?php echo $locationMessage; ?>
<select name="ll" class="select-form-style">
<option>- Select Location -</option>
<?php
foreach ($locations as $location) {
$selected = (!empty($ll) && $ll == $location) ? 'selected="selected"' : '';
?>
<option value="<?php echo $location;?>" <?php echo $selected;?>><?php echo $location;?></option>
<?php
}
?>
</select>
</div>
</div>
<div class="fieldBox">
<div class="label"><p class="bold">Schedule</p></div>
<div class="field"><?php echo $seasonMessage; ?>
<select name="cc" class="select-form-style">
<option>- Select Schedule -</option>
<?php
foreach ($season as $season) {
$selected = (!empty($cc) && $cc == $season) ? 'selected="selected"' : '';
?>
<option value="<?php echo $season;?>" <?php echo $selected;?>><?php echo $season;?></option>
<?php
}
?>
</select>
</div>
</div>
<div class="fieldBox">
<div class="label"><p class="bold">First Name</p></div>
<div class="field"><?php echo $fnameMessage; ?>
<input type="text" title="First Name" name="fname" value="<?php echo $fname; ?>"
maxlength="32" class="fnameField" autocomplete="on" />
</div>
</div>
<div class="fieldBox">
<div class="label"><p>Middle</p></div>
<div class="field">
<input type="text" title="Middle Name" name="mname" value="<?php echo $mname; ?>"
maxlength="20" class="mnameField" autocomplete="on" />
</div>
</div>
<div class="fieldBox">
<div class="label"><p class="bold">Last Name</p></div>
<div class="field"><?php echo $lnameMessage; ?>
<input type="text" title="Last Name" name="lname" value="<?php echo $lname; ?>"
maxlength="32" class="lnameField" autocomplete="on" />
</div>
</div>
<div class="fieldBox">
<div class="label"><p class="bold">Parent/Guardian Name</p></div>
<div class="field"><?php echo $pnameMessage; ?>
<input type="text" title="Parent Name" name="pname" value="<?php echo $pname; ?>"
maxlength="32" class="pnameField" autocomplete="on" />
</div>
</div>
<div class="fieldBox">
<div class="label"><p class="bold">Birthday</p></div>
<div class="field"><?php echo $monthMessage; ?>
<select name="mm" class="select-form-style">
<option>
- Select Month -
</option>
<?php
foreach ($months as $month) {
$selected = (!empty($mm) && $mm == $month) ? 'selected="selected"' : '';
?>
<option value="<?php echo $month;?>" <?php echo $selected;?>>
<?php echo $month;?>
</option>
<?php
}
?>
</select>
</div>
</div>
<div class="fieldBox">
<div class="label"><p class="bold">Day</p></div>
<div class="field"><?php echo $dayMessage; ?>
<select name="dd" class="select-form-style">
<option>- Select Day -</option>
<?php
foreach ($days as $day) {
$selected = (!empty($dd) && $dd == $day) ? 'selected="selected"' : '';
?>
<option value="<?php echo $day;?>" <?php echo $selected;?>><?php echo $day;?></option>
<?php
}
?>
</select>
</div>
</div>
<div class="fieldBox">
<div class="label"><p class="bold">Year</p></div>
<div class="field"><?php echo $yearMessage; ?>
<input type="text" title="Year" name="year" value="<?php echo $year; ?>"
maxlength="4" class="byearField" autocomplete="on" />
</div>
</div>
<div class="fieldBox">
<div class="label"><p class="bold">Age</p></div>
<div class="field"><?php echo $ageMessage; ?>
<input type="text" title="Age" name="age" value="<?php echo $age; ?>"
maxlength="2" class="ageField" autocomplete="on" />
</div>
</div>
<div class="radioFieldBox">
<div class="label"><p class="bold">Gender</p></div>
<div class="field">
<div class="radioGroup">
<input type="radio" id="genderSelectMale" class="" name="gender" value="Male" />
<label for="genderSelectMale"><span></span>Male</label>
<input type="radio" id="genderSelectFemale" class="" name="gender" value="Female" />
<label for="genderSelectFemale"><span></span>Female</label>
</div>
</div>
</div>
<div class="fieldBox">
<div class="label"><p class="bold">School</p></div>
<div class="field"><?php echo $schoolMessage; ?>
<input type="text" title="School" name="school" value="<?php echo $school; ?>"
maxlength="30" class="schoolField" autocomplete="on" />
</div>
</div>
<div class="fieldBox">
<div class="label"><p class="bold">Home Address</p></div>
<div class="field"><?php echo $addyMessage; ?>
<input type="text" title="Street Address" name="address" value="<?php echo $address; ?>"
maxlength="30" class="addyField" autocomplete="on" />
</div>
</div>
<div class="fieldBox">
<div class="label"><p class="bold">City</p></div>
<div class="field"><?php echo $cityMessage; ?>
<input type="text" title="City" name="city" value="<?php echo $city; ?>"
class="cityField" autocomplete="on" />
</div>
</div>
<div class="fieldBox">
<div class="label"><p class="bold">State</p></div>
<div class="field"><?php echo $cityMessage; ?>
<input type="text" title="State" name="state" value="<?php echo $state; ?>"
maxlength="2" class="stateField" autocomplete="on" />
</div>
</div>
<div class="fieldBox">
<div class="label"><p class="bold">Zip</p></div>
<div class="field"><?php echo $zipMessage; ?>
<input type="text" title="Zip Code" name="zip" value="<?php echo $zip; ?>"
maxlength="9" class="zipField" autocomplete="on" />
</div>
</div>
<div class="fieldBox">
<div class="label"><p class="bold">Phone</p></div>
<div class="field"><?php echo $phoneMessage; ?>
<input type="text" title="Phone Number" name="phone" value="<?php echo $phone; ?>"
maxlength="14" class="phoneField" autocomplete="on" />
</div>
</div>
<div class="fieldBox">
<div class="label"><p>Alternate Phone</p></div>
<div class="field">
<input type="text" title="Alternate Phone Number" name="altph" value="<?php echo $altph; ?>"
maxlength="14" class="altPhoneField" autocomplete="on" />
</div>
</div>
<div class="fieldBox">
<div class="label"><p class="bold">Email</p></div>
<div class="field"><?php echo $emailMessage; ?>
<input type="text" title="Email Address" name="email" value='<?php echo $email; ?>'
maxlength="30" class="emailField" autocomplete="on" />
</div>
</div>
<div class="fieldBox">
<div class="label"><p>Special Needs</p></div>
<div class="field">
<div class="GroupSelect">
<Input type = 'Checkbox' id="sn" Name='sn' class="sn" value="Yes" <?php echo
(!empty($sn)) ? 'checked="checked"' : '';?> /><label for="sn"><span></span></label>
</div>
</div>
</div>
<p class="textareaStyle">
Health Problems or Allergies
<textarea name="hp" value='<?php echo $hp; ?>' class="healthAllergyField"
id="contact"></textarea>
</p>
</section>
<section class="agreement"><?php echo $parentMessage; ?>
<p class="bold">
PARENT/GUARDIAN AUTHORIZATION:
</p>
<section>
<Input type = 'Checkbox' id="autho" Name ='authorization' class="authorization" value ="1" <?php echo
(!empty($authorization)) ? 'checked="checked"' : '';?> /><label for="autho"><span></span>I understand the traffic
safety education course consists of 30 clock-hours of classroom instruction, 6
hours of behind-the-wheel instruction and 6 hours of in-car observation. I also
understand that instruction is provided by a properly certified instructor licensed
by the Idaho Department of Education and the Idaho Bureau of Occupational Licenses,
and the behind-the-wheel training takes place in a dual-control vehicle that is
adequately insured. I accept the fact that the Buckle-UP Driving School, LLC will
not be responsible for any driving the student may do outside the Driver Education
program. In addition I acknowledge that portions of the student participation in
this traffic safety education course may be videotaped for feedback and grading as
well as for use in future training courses. </label>
</section>
<section>
<p>
<input type="checkbox" id="parentPack" title="Packet" name="packet" value="1" <?php echo
(!empty($packet)) ? 'checked="checked"' : '';?> /><label for="parentPack"><span></span>I have read the <a href=
"pdf_server.php?file=pdfs/BUCKLE_UP_INFORMATION_PACKET" class="registerLink">Student/Parent or Guardian
Information Packet</a><a href=
"pdfs/BUCKLE_UP_INFORMATION_PACKET.pdf" class="registerLinkMobile">Student/Parent or Guardian
Information Packet</a> for Driver Education and hereby give approval for the above
student to participate in the course.</label>
</p>
</section>
<div class="signature">
<section>
<p>
<input type="checkbox" id="signature" title="Parent/Guardian Signature" name="signature" value="1" <?php echo
(!empty($signature)) ? 'checked="checked"' : '';?> /><label for="signature"><span></span>By checking this box you are registering the above student for Driver's Education with Buckle-Up Driving School and are stating the above information is accurate to the best of your knowlegde. Any false statements or registration by anyone other than the Parent/Guardian can and will be held accountable by the laws within your State. The registration fee of $275 for class in Priest River/Sandpoint will need to be paid in full by the end of the class and $375 for the online class.</label>
</p>
</section>
<input type="submit" name="submit" value="Send" class="formButton">
</div>
</section>
</form>
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