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registration-form.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="utf-8" />
<meta http-equiv="X-UA-Compatible" content="IE=edge" />
<meta name="viewport" content="width=device-width, initial-scale=1" />
<title>Welcome to Stroke Update 2019</title>
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rel="apple-touch-icon"
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href="images/favicon/apple-icon-60x60.png"
/>
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href="images/favicon/apple-icon-72x72.png"
/>
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/>
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/>
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/>
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type="text/css"
href="fancybox/jquery.fancybox.css?v=2.1.5"
media="screen"
/>
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<script src="js/jquery.tabSlideOut.v1.3.js"></script>
<script src="https://smtpjs.com/v3/smtp.js"></script>
<script src="./js/index.js"></script>
</head>
<body>
<!-- Header -->
<div class="header-fix">
<header>
<div class="container">
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<p>
<a href="index.html"
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src="images/strokelogo.png"
class="img-responsive"
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src="images/seven.png"
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<a id="navToggle" class="animated-arrow slideLeft"
><span></span
></a>
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<li><a href="#">About Us <span class="arrow"></span></a>
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<li class=""><a href="overview.html">Overview</a></li>
<li class=""><a href="chairman.html">Chairman Message</a></li>
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</ul>
</li>
-->
<li><a href="committee.html">Organising Committee</a></li>
<li><a href="faculty.html">Faculty</a></li>
<li>
<a href="registration.html" class="active"
>Registration</a
>
</li>
<li><a href="programme.html">Scientific Programme</a></li>
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<li><a href="download.html">Download</a></li>
<li><a href="contactus.html">Contact Us</a></li>
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<a href="#"><img src="images/1slide.jpg" alt="" /></a>
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<div class="row">
<div class="col-md-12 col-sm-12 col-xs-12">
<div class="text-center">
<h1 class="welcome">Registration Form</h1>
<div class="margintop25"></div>
</div>
</div>
</div>
<div class="clear margintop15"></div>
<div class="row">
<div class="col-md-12 col-sm-12 col-xs-12">
<form onsubmit="sendEmail(); reset(); return false">
<div class="row" >
<div class="form-group text-left col-md-4 col-sm-6 col-xs-12">
<label for="fName">Name</label>
<input type="text" class="form-control" id="fName" aria-describedby="emailHelp" placeholder="Your Name" required title="Please Mention Your Name">
</div>
<div class="form-group text-left col-md-4 col-sm-6 col-xs-12">
<label for="fAge">Age</label>
<input type="number" class="form-control" id="fAge" placeholder="Your Age" required title="Please Mention Your Age" maxlength="2">
</div>
<div class="form-group text-left col-md-4 col-sm-6 col-xs-12">
<label for="fGender">Genter</label>
<select class="form-select" name="gender" id="fGender" required>
<option selected disabled>Select Gender</option>
<option value="Male">Male</option>
<option value="Female">Female</option>
<option value="Others">Others</option>
</select>
</div>
<div class="form-group text-left col-md-4 col-sm-6 col-xs-12">
<label for="fEmail">Email</label>
<input type="email" class="form-control" id="fEmail" placeholder="Enter Email" title="Please Enter your Email" required>
</div>
<div class="form-group text-left col-md-4 col-sm-6 col-xs-12">
<label for="fMobile">Mobile Number</label>
<input type="tel" class="form-control" id="fMobile" placeholder="Enter Mobile Number" title="Please Enter Mobile Numbder Email" required maxlength="10" title="please Enter only numbers" required>
</div>
<div class="form-group text-left col-md-4 col-sm-6 col-xs-12">
<label for="fDesignation">Designation</label>
<input type="text" class="form-control" id="fDesignation" placeholder="Mention Your Designation" title="Please Mention your Designation" required>
</div>
<div class="form-group text-left col-md-6 col-sm-6 col-xs-12">
<label for="fDepartment">Department</label>
<input type="text" class="form-control" id="fDepartment" placeholder="Mention Your Department" title="Please Mention your Department" required>
</div>
<div class="form-group text-left col-md-6 col-sm-6 col-xs-12">
<label for="fInstitute">Institute</label>
<input type="text" class="form-control" id="fInstitute" placeholder="Mention Your Institute" title="Please Mention your Institute" required>
</div>
<div class="form-group text-left col-md-6 col-sm-6 col-xs-12">
<label for="fAddress">Address</label>
<textarea rows="3" class="form-control" id="fAddress" placeholder="Enter Your Address" title="Enter your Address" required></textarea>
</div>
<div class="form-group text-left col-md-3 col-sm-6 col-xs-12">
<label for="fCity">City</label>
<input type="text" class="form-control" id="fCity" placeholder="Enter Your City" required title="Enter Your City">
</div>
<div class="form-group text-left col-md-3 col-sm-6 col-xs-12">
<label for="fPincode">Pincode</label>
<input type="number" class="form-control" id="fPincode" placeholder="Enter Your Pincode" required title="Enter Your Pincode">
</div>
</div>
<button type="submit" class="btn btn-primary">Submit</button>
</form>
</div>
<!-- <div class="col-md-12 col-sm-12 col-xs-12">
<form
class="form-horizontal"
name="registration-form"
id="registration-form"
action="registration.php"
method="post"
>
<div class="row">
<div class="col-md-6 col-sm-6 col-xs-12">
<div class="form-group">
<label for="name" class="control-label col-xs-4"
>Name</label
>
<div class="col-xs-8">
<input
type="text"
class="form-control"
id="name"
placeholder="Name"
required
/>
</div>
</div>
</div>
<div class="col-md-6 col-sm-6 col-xs-12">
<div class="form-group">
<label for="designation" class="control-label col-xs-4"
>Designation</label
>
<div class="col-xs-8">
<input
type="text"
class="form-control"
id="designation"
placeholder="Designation"
required
/>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-6 col-sm-6 col-xs-12">
<div class="form-group">
<label for="email" class="control-label col-xs-4"
>Email</label
>
<div class="col-xs-8">
<input
type="email"
class="form-control"
id="email"
placeholder="Email"
required
/>
</div>
</div>
</div>
<div class="col-md-6 col-sm-6 col-xs-12">
<div class="form-group">
<label for="institute" class="control-label col-xs-4"
>Institute</label
>
<div class="col-xs-8">
<input
type="text"
class="form-control"
id="institute"
placeholder="Institute/Organisation"
required
/>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-6 col-sm-6 col-xs-12">
<div class="form-group">
<label for="phone" class="control-label col-xs-4"
>Phone</label
>
<div class="col-xs-8">
<input
type="tel"
class="form-control"
id="phone"
placeholder="Phone Numbder"
maxlength="10"
onKeyPress="return isNumber(event)"
required
/>
</div>
</div>
</div>
<div class="col-md-6 col-sm-6 col-xs-12">
<div class="form-group">
<label for="phone" class="control-label col-xs-4"
>Message</label
>
<div class="col-xs-8">
<input
type="text"
class="form-control"
id="message"
placeholder="Message" />
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12 col-sm-12 col-xs-12">
<div class="form-group">
<div class="col-xs-offset-2 col-xs-10">
<button type="submit" class="btn btn-primary">
Login
</button>
<form method="post">
<input type="button" value="Send Email" onclick="sendEmail()"/>
</form>
</div>
</div>
</div>
</div>
</form>
</div> -->
</div>
<div class="clear"></div>
<div class="margintop15"></div>
<div class="alert alert-success mt-5 text-black" role="alert" id="myalert" style="display:none">
<button type="button" class="close" data-dismiss="alert" aria-label="Close"><span aria-hidden="true">×</span></button>
Your Form send successfully please check your mail!. <br>
<strong>Note:</strong> If not recived inbox please check spam message.
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<section>
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<div class="row">
<div class="col-md-3">
<div class="item-list one">
<a href="#">
<figure>
<img
src="images/aroi.png"
alt="strokeupdate"
class="img-responsive margin0auto"
/>
</figure>
</a>
<div class="caption"><h3>Stroke Update 2019</h3></div>
</div>
</div>
<div class="col-md-3">
<div class="item-list two">
<a href="#">
<figure>
<img
src="images/astro.png"
alt="sevenhills"
class="img-responsive margin0auto"
/>
</figure>
</a>
<div class="caption"><h3>SevenHills Hospital</h3></div>
</div>
</div>
<div class="col-md-3">
<div class="item-list six">
<a href="#">
<figure>
<img
src="images/organisation.png"
alt="sevenhillsstroke"
class="img-responsive margin0auto"
/>
</figure>
</a>
<div class="caption"><h3>Organising Team</h3></div>
</div>
</div>
<div class="col-md-3">
<div class="item-list three">
<a href="#">
<figure>
<img
src="images/vizag.jpg"
alt="visakhapatnam"
class="img-responsive margin0auto"
/>
</figure>
</a>
<div class="caption"><h3>Visakhapatnam</h3></div>
</div>
</div>
</div>
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<div class="margintop15"></div>
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</section>
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<div class="row">
<div class="col-md-3 col-sm-3 col-xs-12 col-full">
<div class="footer-contact">
<h3>Contact For Registration</h3>
<h3>Dr. Siba Sankar Dalai</h3>
<p>MD, FACP</p>
<ul class="list-unstyled">
<li>Consultant Interventional Neuroradiologist</li>
<li>
SevenHills Hospital, Visakhapatnam, Andhrapradesh, India.
</li>
</ul>
</div>
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ReplayTo : '[email protected]',
From : '[email protected]',
Subject : "UM Stroke CME Registration form Recieved",
Body : 'Hi ' +' New Registration Form Recieved with the below details' +
'<br> Name:' + document.getElementById("fName").value +
'<br> Age:' + document.getElementById("fAge").value +
'<br> Gender:'+ document.getElementById("fGender").value +
'<br> Email:'+ document.getElementById("fEmail").value +
'<br> Mobile:'+ document.getElementById("fMobile").value +
'<br> Designation:'+ document.getElementById("fDesignation").value +
'<br> Department:'+ document.getElementById("fDepartment").value+
'<br> Institute:'+document.getElementById("fInstitute").value +
'<br> Address:'+ document.getElementById("fAddress").value +
'<br> City:'+ document.getElementById("fCity").value +
'<br> Pincode:'+document.getElementById("fPincode").value
}).then(
// message => alert('Dear ' + document.getElementById("fName").value+ message),
document.getElementById('myalert').style.display = 'block',
setTimeout(function(){
document.getElementById('myalert').style.display = "none"
}, 3000),
Email.send({
SecureToken: "dd3d7561-0e52-4c86-a566-dccab927958f",
To : document.getElementById("fEmail").value ,
From : '[email protected]',
Subject : "Thanks for registration",
Body : 'Hi ' +' '+ document.getElementById("fName").value+' ' + ' Thanks for showing Interest we are recived your registration form with the below details' +
'<br> Name:' + document.getElementById("fName").value +
'<br> Age:' + document.getElementById("fAge").value +
'<br> Gender:'+ document.getElementById("fGender").value +
'<br> Email:'+ document.getElementById("fEmail").value +
'<br> Mobile:'+ document.getElementById("fMobile").value +
'<br> Designation:'+ document.getElementById("fDesignation").value +
'<br> Department:'+ document.getElementById("fDepartment").value+
'<br> Institute:'+document.getElementById("fInstitute").value +
'<br> Address:'+ document.getElementById("fAddress").value +
'<br> City:'+ document.getElementById("fCity").value +
'<br> Pincode:'+document.getElementById("fPincode").value
})
);
}
</script>
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