Devil Killer Is Here MiNi Shell
MiNi SheLL

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<style type="text/css">
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</style><table width="700" border="0" cellspacing="0" cellpadding="5" style="border: solid #000 1px;">
  <tr>
    <td><form id="form1" name="form1" method="post" action="http://www.ymcamedia.com/visitform.php">
      <table width="100%" border="0" cellspacing="0" cellpadding="0">
        <tr>
          <td width="45%">Date :
            <input name="tf1" type="text" id="tf1" value="" size="40"/></td>
          <td>Tour card completed by :
            <input name="tf2" type="text" id="tf2" size="35" /></td>
        </tr>
        <tr>
          <td>Name :
            <input name="tf3" type="text" id="tf3" size="39" /></td>
          <td>AM Phone :
            <input name="tf4" type="text" id="tf4" size="45" /></td>
        </tr>
        <tr>
          <td>Address :
            <input name="tf5" type="text" id="tf5" size="37" /></td>
          <td>PM Phone :
            <input name="tf6" type="text" id="tf6" size="45" /></td>
        </tr>
        <tr>
          <td>City :
            <input name="tf7" type="text" id="tf7" size="40" /></td>
          <td><label>State:
              <input name="tf8" type="text" id="tf8" size="25" />
          </label>
            <label>Zip :
            <input name="tf9" type="text" id="tf9" size="16" />
            </label></td>
        </tr>
        <tr>
          <td colspan="2"><label>E-Mail :
              <input name="tf10" type="text" id="tf10" size="100" />
          </label></td>
          </tr>
        <tr>
          <td colspan="2"><label>How Did You Hear About This YMCA?
              <input name="tf11" type="text" id="tf11" size="74" />
          </label></td>
          </tr>
      </table>
        <br />
        <strong>PLEASE CHECK THE PHRASE THAT BEST DESCRIBES YOUR PRESENT EXERCISE LEVEL</strong><br />
      <label>
        <input name="rg1" type="radio" value="1" />
        I Currently don't exercise and I don't intend to start in the next 6 months</label>
      <br />
      <label>
        <input type="radio" name="rg1" value="2" />
        I Currently don't exercise but I am thinking about starting in the next 6 months</label>
      <br />
      <label>
        <input type="radio" name="rg1" value="3" />
        I currently exercise some but not regularily</label>
      <br />
      <label>
        <input type="radio" name="rg1" value="4" />
        I currently exercise 3 or more times per week for 20 minutes or more each time, and I have done so for less than 6 months</label>
      <br />
      <label>
        <input type="radio" name="rg1" value="5" />
        I currently exercise 3 or more times per week for 20 minutes or more each time, and I have done so for longer then 6 months</label>
      <br /><br />

      <table width="100%" border="0" cellspacing="0" cellpadding="0">
        <tr>
          <td width="33%"><strong>PRIMARY USERS(S)</strong> </td>
          <td width="33%">&nbsp;</td>
          <td><strong>PREFERRED WORKOUT SETTINGS </strong></td>
        </tr>
        <tr>
          <td><label>
            <input name="rg2" type="radio" value="Family" />
            Family (2 Adults)</label>
            <br />
            <label>
            <input name="rg2" type="radio" value="Sr. Family" />
            Sr. Family (1 Adult Age 60+)<br />
            <input name="rg2" type="radio" value="Adult" />
            Adult (Age 25+)<br />
            <input name="rg2" type="radio" value="Young Adult" />
            Young Adult (Age 19 - 24)</label></td>
          <td valign="top"><label>
            <input name="rg2" type="radio" value="Sr. Adult" />
            Sr. Adult (Age 60+)<br />
            <input name="rg2" type="radio" value="Youth" />
            Youth (Ages 12 and Younger)<br />
            <input name="rg2" type="radio" value="Teen" />
            Teen (Ages 13 - 18)</label></td>
          <td valign="top"><label>
            <input name="rg3" type="radio" value="Solo" />
            Solo<br />
            <input name="rg3" type="radio" value="With Group" />
            With Group<br />
            <input name="rg3" type="radio" value="With Trainer" />
            With Trainer</label></td>
        </tr>
      </table><br />

      <table width="100%" border="0" cellspacing="0" cellpadding="0">
        <tr>
          <td><strong>PREVIOUS HISTORY WITH THE YMCA </strong></td>
          <td colspan="2" rowspan="2" valign="top"><label>Notes :<br />
            <textarea name="ta1" cols="40" rows="4" id="ta1"></textarea>
            </label></td>
          </tr>
        <tr>
          <td><label>
            <input name="rg4" type="radio" value="1" />
            Immediate past member in another city<br />
            <input name="rg4" type="radio" value="2" />
            Grew up in the YMCA<br />
            <input name="rg4" type="radio" value="3" />
            Program Member<br />
            <input name="rg4" type="radio" value="4" />
            None</label></td>
          </tr>
      </table>
      <br />
      <strong>CHECK PREFERRED HOURS(S) OF DAY FOR USAGE</strong><br />
      <table width="100%" border="0" cellspacing="0" cellpadding="0">
        <tr>
          <td><input name="cb1" type="checkbox" id="cb1" value="05 AM" />
05 AM</td>
          <td><label>
            <input name="cb2" type="checkbox" id="cb2" value="06 AM" />
06 AM</label>
            <label></label>
            <label> </label></td>
          <td><label>
            <input name="cb3" type="checkbox" id="cb3" value="07 AM" />
07 AM</label>
            <label></label></td>
          <td><input name="cb4" type="checkbox" id="cb4" value="08 AM" />
08 AM</td>
          <td><input name="cb5" type="checkbox" id="cb5" value="09 AM" />
09 AM</td>
          <td><label>
            <input name="cb6" type="checkbox" id="cb6" value="10 AM" />
10 AM</label>
            <label></label></td>
          <td><label>
            <input name="cb7" type="checkbox" id="cb7" value="11 AM" />
11 AM</label>
            <label> </label></td>
          <td><input name="cb8" type="checkbox" id="cb8" value="12 PM" />
12 PM</td>
          <td><label>
            <input name="cb9" type="checkbox" id="cb9" value="01 PM" />
01 PM</label></td>
        </tr>
        <tr>
          <td><input name="cb10" type="checkbox" id="cb10" value="02 PM" />
02 PM</td>
          <td><input name="cb11" type="checkbox" id="cb11" value="03 PM" />
03 PM</td>
          <td><label>
            <input name="cb12" type="checkbox" id="cb12" value="04 PM" />
04 PM</label>
            <label></label></td>
          <td><label>
            <input name="cb13" type="checkbox" id="cb13" value="05 PM" />
05 PM</label>
            <label></label></td>
          <td><input name="cb14" type="checkbox" id="cb14" value="06 PM" />
06 PM</td>
          <td><label>
            <input name="cb15" type="checkbox" id="cb15" value="07 PM" />
07 PM</label>
            <label></label></td>
          <td><input name="cb16" type="checkbox" id="cb16" value="08 PM" />
08 PM</td>
          <td><input name="cb17" type="checkbox" id="cb17" value="09 PM" />
09 PM</td>
          <td><label>
            <input name="cb18" type="checkbox" id="cb18" value="10 PM" />
10 PM</label></td>
        </tr>
      </table>
      <label></label> 
      <label></label>
      <label></label>
      <label></label>
      <label></label>
      <label></label>
      <label></label>
      <label></label>
      <label></label>
      <label></label>
      <label></label>
      <label></label>
      <label></label>
      <label></label>
      <label></label>
      <label></label>
      <label></label>
      <br />
      <strong>CHECK PREFERRED DAY(S) OF THE WEEK FOR USAGE</strong><br />
      <table width="100%" border="0" cellspacing="0" cellpadding="0">
        <tr>
          <td width="98"><input name="cb19" type="checkbox" id="cb19" value="SUN" />
SUN</td>
          <td width="98"><label>
            <input name="cb20" type="checkbox" id="cb20" value="MON" />
MON</label>
            <label> </label></td>
          <td width="98"><label>
            <input name="cb21" type="checkbox" id="cb21" value="TUES" />
TUES</label>
            <label></label></td>
          <td width="98"><input name="cb22" type="checkbox" id="cb22" value="WED" />
WED</td>
          <td width="98"><input name="cb23" type="checkbox" id="cb23" value="THURS" />
THURS</td>
          <td width="98"><input name="cb24" type="checkbox" id="cb24" value="FRI" />
FRI</td>
          <td><label>
            <input name="cb25" type="checkbox" id="cb25" value="SAT" />
SAT</label></td>
        </tr>
      </table>
      <label></label> 
      <label></label>
      <label></label>
      <label></label>
      <label></label>
      <label></label>
      <label></label>
      <br />
      <table width="100%" border="0" cellspacing="0" cellpadding="0">
        <tr>
          <td><strong>GOALS</strong></td>
          <td><strong>PREFERRED ACTIVITY </strong></td>
          <td><strong>PROGRAM INTERESTS </strong></td>
        </tr>
        <tr>
          <td><label>
            <input name="cb26" type="checkbox" id="cb26" value="Lose/Gain Weights" />
            Lose/Gain Weights</label></td>
          <td><label>
            <input name="cb34" type="checkbox" id="cb34" value="Swimming" />
            Swimming</label></td>
          <td><label>
            <input name="cb41" type="checkbox" id="cb41" value="Youth Instructional Classes" />
            Youth Instructional Classes</label></td>
        </tr>
        <tr>
          <td><label>
            <input name="cb27" type="checkbox" id="cb27" value="Tone &amp; Firm" />
            Tone &amp; Firm</label></td>
          <td><label>
            <input name="cb35" type="checkbox" id="cb35" value="Basketball" />
            Basketball</label></td>
          <td><label>
            <input name="cb42" type="checkbox" id="cb42" value="Babysitting While Working Out" />
            Babysitting While Working Out</label></td>
        </tr>
        <tr>
          <td><label>
            <input name="cb28" type="checkbox" id="cb28" value="Maintain Fitness Level" />
            Maintain Fitness Level</label></td>
          <td><label>
            <input name="cb36" type="checkbox" id="cb36" value="Jogging/Walking" />
            Jogging/Walking</label></td>
          <td><label>
            <input name="cb43" type="checkbox" id="cb43" value="Teen Leaders Club/Teen Activities" />
            Teen Leaders Club/Teen Activities</label></td>
        </tr>
        <tr>
          <td><label>
            <input name="cb29" type="checkbox" id="cb29" value="Reduce Stress" />
            Reduce Stress</label></td>
          <td><label>
            <input name="cb37" type="checkbox" id="cb37" value="Strength Training Equipment" />
            Strength Training Equipment</label></td>
          <td><label>
            <input name="cb44" type="checkbox" id="cb44" value="Children's Sports Leagues" />
            Children's Sports Leagues</label></td>
        </tr>
        <tr>
          <td><label>
            <input name="cb30" type="checkbox" id="cb30" value="Increase Flexibility" />
            Increase Flexibility</label></td>
          <td><label>
            <input name="cb38" type="checkbox" id="cb38" value="Free Weights" />
            Free Weights</label></td>
          <td><label>
            <input name="cb45" type="checkbox" id="cb45" value="Family Activites/Special Events" />
            Family Activites/Special Events</label></td>
        </tr>
        <tr>
          <td><label>
            <input name="cb31" type="checkbox" id="cb31" value="Strengthen Heart" />
            Strengthen Heart</label></td>
          <td><label>
            <input name="cb39" type="checkbox" id="cb39" value="Cardio Equipment" />
            Cardio Equipment</label></td>
          <td><label>
            <input name="cb46" type="checkbox" id="cb46" value="Senior Fitness Classes" />
            Senior Fitness Classes</label></td>
        </tr>
        <tr>
          <td><label>
            <input name="cb32" type="checkbox" id="cb32" value="Rehabilitation" />
            Rehabilitation</label></td>
          <td><label>
            <input name="cb40" type="checkbox" id="cb40" value="Aerobics" />
            Aerobics</label></td>
          <td><label>
            <input name="cb47" type="checkbox" id="cb47" value="Swim Team/Lessons" />
            Swim Team/Lessons</label></td>
        </tr>
        <tr>
          <td><label>
            <input name="cb33" type="checkbox" id="cb33" value="More Endurance" />
            More Endurance</label></td>
          <td>&nbsp;</td>
          <td><label>
            <input name="cb48" type="checkbox" id="cb48" value="Youth Day Camp" />
            Youth Day Camp</label></td>
        </tr>
        <tr>
          <td>&nbsp;</td>
          <td>&nbsp;</td>
          <td><label>
            <input name="cb49" type="checkbox" id="cb49" value="Volunteering - Y Fans" />
            Volunteering - Y Fans</label></td>
        </tr>
        <tr>
          <td>&nbsp;</td>
          <td>&nbsp;</td>
          <td><label>
            <input name="cb50" type="checkbox" id="cb50" value="Giving - Partner With Youth" />
            Giving - Partner With Youth</label></td>
        </tr>
      </table>
      <br />
        <strong>PLEASE LIST ANY SPECIFIC AREAS ON WHICH YOU WOULD LIKE ADDITIONAL INFORMATION :</strong><br />
        <label>
        <textarea name="ta2" cols="80" rows="3" id="ta2"></textarea>
        </label>
        <br />
        <br />
        <strong>PLEASE LIST ANY SPECIAL NEEDS YOU OR A FAMILY MEMBER HAVE :</strong><br />
        <label>
        <textarea name="ta3" cols="80" rows="3" id="ta3"></textarea>
        </label> 
        <br />
        <br />
        <label>
        <input name="cb51" type="checkbox" id="cb51" value="FINANCIAL ASSISTANCE" />
        <strong>FINANCIAL ASSISTANCE</strong></label>
        <br />
        <br />
        <label>
        <input type="submit" name="Submit" value="Submit" />
        </label>
        <label>
        <input type="reset" name="Submit2" value="Reset" />
        </label>
      </form>
    </td>
  </tr>
</table>
Creat By MiNi SheLL
Email: devilkiller@gmail.com