{START_FORM}
<table>
    <tr><td>{FIRST_NAME_LABEL}</td><td>{FIRST_NAME}</td></tr>
    <tr><td>{LAST_NAME_LABEL}</td><td>{LAST_NAME}</td></tr>
    <!-- BEGIN email --><tr><td>{EMAIL_LABEL}</td><td>{EMAIL}</td></tr><!-- END email -->
    <!-- BEGIN birthdate --><tr><td>{BIRTHDATE_LABEL}</td><td>{BIRTHDATE_MONTH} {BIRTHDATE_DAY} {BIRTHDATE_YEAR}</td></tr><!-- END birthdate -->
    <!-- BEGIN gender --><tr><td>{GENDER_LABEL}</td><td>{GENDER_1} {GENDER_1_LABEL}<br />
                                                        {GENDER_2} {GENDER_2_LABEL}</td></tr><!-- END gender -->
    <!-- BEGIN reasons --><tr><td>{REASON_ID_LABEL}</td><td>{REASON_ID}</td></tr><!-- END reasons -->
</table>
{SUBMIT} {END_FORM}