<% ' FP_ASP ASP Automatically generated by a Frontpage Component. Do not Edit. On Error Resume Next Session("FP_OldCodePage") = Session.CodePage Session("FP_OldLCID") = Session.LCID Session.CodePage = 1252 Err.Clear strErrorUrl = "" If Request.ServerVariables("REQUEST_METHOD") = "POST" Then If Request.Form("VTI-GROUP") = "0" Then Err.Clear Set fp_conn = Server.CreateObject("ADODB.Connection") FP_DumpError strErrorUrl, "Cannot create connection" Set fp_rs = Server.CreateObject("ADODB.Recordset") FP_DumpError strErrorUrl, "Cannot create record set" fp_conn.Open Application("teacherreferralform_ConnectionString") FP_DumpError strErrorUrl, "Cannot open database" fp_rs.Open "Results", fp_conn, 1, 3, 2 ' adOpenKeySet, adLockOptimistic, adCmdTable FP_DumpError strErrorUrl, "Cannot open record set" fp_rs.AddNew FP_DumpError strErrorUrl, "Cannot add new record set to the database" Dim arFormFields0(12) Dim arFormDBFields0(12) Dim arFormValues0(12) arFormFields0(0) = "TeacherComments" arFormDBFields0(0) = "TeacherComments" arFormValues0(0) = Request("TeacherComments") arFormFields0(1) = "YoungestAge" arFormDBFields0(1) = "YoungestAge" arFormValues0(1) = Request("YoungestAge") arFormFields0(2) = "TeacherLooking" arFormDBFields0(2) = "TeacherLooking" arFormValues0(2) = Request("TeacherLooking") arFormFields0(3) = "TeacherQualifications" arFormDBFields0(3) = "TeacherQualifications" arFormValues0(3) = Request("TeacherQualifications") arFormFields0(4) = "TeacherEmail" arFormDBFields0(4) = "TeacherEmail" arFormValues0(4) = Request("TeacherEmail") arFormFields0(5) = "TeacherFirstName" arFormDBFields0(5) = "TeacherFirstName" arFormValues0(5) = Request("TeacherFirstName") arFormFields0(6) = "TeacherPhone" arFormDBFields0(6) = "TeacherPhone" arFormValues0(6) = Request("TeacherPhone") arFormFields0(7) = "TeacherCity" arFormDBFields0(7) = "TeacherCity" arFormValues0(7) = Request("TeacherCity") arFormFields0(8) = "TeachAdults" arFormDBFields0(8) = "TeachAdults" arFormValues0(8) = Request("TeachAdults") arFormFields0(9) = "TeacherState" arFormDBFields0(9) = "TeacherState" arFormValues0(9) = Request("TeacherState") arFormFields0(10) = "TeacherStatus" arFormDBFields0(10) = "TeacherStatus" arFormValues0(10) = Request("TeacherStatus") arFormFields0(11) = "TeacherLastName" arFormDBFields0(11) = "TeacherLastName" arFormValues0(11) = Request("TeacherLastName") FP_SaveFormFields fp_rs, arFormFields0, arFormDBFields0 If Request.ServerVariables("REMOTE_HOST") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("REMOTE_HOST"), "Remote_computer_name" End If If Request.ServerVariables("HTTP_USER_AGENT") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("HTTP_USER_AGENT"), "Browser_type" End If FP_SaveFieldToDB fp_rs, Now, "Timestamp" If Request.ServerVariables("REMOTE_USER") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("REMOTE_USER"), "User_name" End If fp_rs.Update FP_DumpError strErrorUrl, "Cannot update the database" fp_rs.Close fp_conn.Close Session("FP_SavedFields")=arFormFields0 Session("FP_SavedValues")=arFormValues0 Session.CodePage = Session("FP_OldCodePage") Session.LCID = Session("FP_OldLCID") Response.Redirect "teacherreferralform-conf.asp" End If End If Session.CodePage = Session("FP_OldCodePage") Session.LCID = Session("FP_OldLCID") %> Teacher Referral Request Form

 

 

Fill Out This Form If You Are a Teacher
Willing to Have Potential Students Contact You Directly


 

 

Please fill in to following form in order to allow potential students in your area to contact you. There is no charge for this service.
All information you enter in this form will be published on the website.  
So, if you do not want your phone number or email published, then do not enter them in the blank.   Please note, however, potential students will need a way to contact you

* Indicates you need to fill in the blank.
.

*Your First Name    
*Your Last Name  
*Your City  
*Your State  
Your Phone Number  
Your Email Address  

 

*Youngest Age Student
You will accept
 

 

Do you teach adults?  

 

Describe what you are looking for in a student:

 

 
*Describe your qualifications and experience as a teacher

 

 
Other Comments:  

 

Your Status
     

 

 

 

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