<?xml version="1.0" encoding="utf-8"?>
<!DOCTYPE html
PUBLIC "-//W3C//DTD XHTML Basic 1.0//EN"
"http://www.w3.org/TR/xhtml-basic/xhtml-basic10.dtd">
<html xmlns="http://www.w3.org/1999/xhtml" lang="en-US">
<head>
<title>Application for HILIS Registration</title>
<link rel="stylesheet" type="text/css" href="/css/site.css" />
<script language="javascript" type="text/javascript">
<!-- Hide script
//<![CDATA[
function showhide_source(f,v) {
var t = f.elements['other_source'];
if(v=='OTHER'){
t.style.visibility='visible'
}
else{
t.style.visibility='hidden'
}
}
function showhide_role(f,v) {
var t = f.elements['other_role'];
if(v=='OTHER'){
t.style.visibility='visible'
}
else{
t.style.visibility='hidden'
}
}
onload = function() {
[% UNLESS vars.location.match('OTHER') %]
document.application.other_source.style.visibility='hidden'
[% END %]
[% UNLESS vars.designation.match('OTHER') %]
document.application.other_role.style.visibility='hidden'
[% END %]
}
//]]> End script hiding -->
</script>
</head>
<body>
[% # PROCESS dumper.tt dump = vars %]
[% # PROCESS dumper.tt dump = errs %]
<div>
<p>
<a name="top">
<img src="/images/logo.jpeg" title="Leeds Teaching Hospitals NHS Trust Logo"
border="0" align="right" alt="Logo"/>
</a>
</p>
<br clear="all" />
<table cellspacing="1" cellpadding="3" border="0" width="100%">
<tr bgcolor="#cbe0eb">
<td align="left" valign="top" class="border">
<b>Welcome to HMDS</b>
</td>
<td align="center" class="border" valign="top" width="50%">
[% USE date(format = '%A, %d %B %Y, %T', locale = 'en_GB');
date.format %]
</td>
<td align="right" width="25%" class="border" valign="top"> </td>
</tr>
</table>
<br />
<table id="main">
<tr>
<td>
<table>
<tr>
<td>
<h2>Application for HILIS Registration</h2>
[% UNLESS send_success # already submitted %]
<p>
Please enter your details below. All fields are required.
</p>
[% END %]
[% IF errs.error_other_role || errs.error_other_source %]
<ul class="dfv_errors">
[% IF errs.error_other_role %]
<li>
please enter an alternative role if selecting 'other'
</li>
[% END %]
[% IF errs.error_other_source %]
<li>
please enter an alternative location if selecting 'other'
</li>
[% END %]
</ul>
[% END %]
[% IF msg %]
<p class="dfv_errors">
Sorry, there is a problem with the mail server and your message was
not sent. Your details have been preserved in the form below, please
try again shortly. The error message was: "[% msg %]". Please copy
this message to <a href="mailto:[% admin %]">HMDS admin</a> if the
error persists. Apologies for the inconvenience.
</p>
[% ELSIF send_success %]
<p class="info">
Your registration details have been submitted. You should receive
an e-mail copy within 24 hours at [% vars.email %], but if not please
contact <a href="mailto:[% admin %]">HMDS admin</a>.
</p>
[% END %]
<form method="post" action="[% %]" name="application"
enctype="application/x-www-form-urlencoded">
<div id="registration">
<table border="0">
<tr>
<td class="red">First Name:</td>
<td colspan="2">
<input type="text" name="first_name" />
[% errs.error_first_name %]
</td>
</tr>
<tr>
<td class="red">Last Name:</td>
<td colspan="2">
<input type="text" name="last_name" />
[% errs.error_last_name %]
</td>
</tr>
<tr>
<td class="red">Location:</td>
<td>
<select name="location"
onchange="showhide_source(this.form,this.value)">
<option value=""></option>
[% FOREACH location IN user_locations.sort %]
<option value="[% location %]">[% location %]</option>
[% END %]
<option disabled>---</option>
<option value="OTHER">Other</option>
</select>
[% errs.error_location %]
</td>
<td>
<textarea name="other_source" id="other_source" rows=1
cols=15></textarea>
</td>
</tr>
<tr>
<td class="red">Department:</td>
<td colspan="2">
<input type="text" name="dept" />
[% errs.error_dept %]
</td>
</tr>
<tr>
<td class="red">Role:</td>
<td>
<select name="designation"
onchange="showhide_role(this.form,this.value)">
<option value=""></option>
[% FOREACH role IN roles.sort;
NEXT IF role.match('^(Administrator|Visitor|Guest|Lab staff)');
%]
<option value="[% role %]">[% role %]</option>
[% END %]
<option disabled>---</option>
<option value="OTHER">Other</option>
</select>
[% errs.error_role %]
</td>
<td>
<textarea name="other_role" rows=1 cols=15></textarea>
</td>
</tr>
<tr>
<td class="red"><div>Departmental</div>address:</div></td>
<td colspan="2">
<textarea name="contact" rows=3 cols=18></textarea>
[% errs.error_contact %]
</td>
</tr>
<tr>
<td class="red">Telephone:</td>
<td colspan="2">
<input type="text" name="tel" />
[% errs.error_tel %]
</td>
</tr>
<tr>
<td class="red">E-mail:</td>
<td>
<input type="text" name="email" />
[% errs.error_email %]
</td>
<td class="right">
re-type e-mail for validation:
<input type="text" name="email2" />
[% errs.error_email2 %]
</td>
</tr>
</table>
<p class="hr"></p>
</div>
[% UNLESS send_success # already submitted %]
<p class="center">
<input type="submit" name="register" value="Submit Registration" />
<input type="reset" value="Reset All Values" />
</p>
[% END %]
</form>
</td>
</tr>
</table>
</td>
</tr>
</table>
</div>
</body>
</html>