Your IP : 216.73.216.40
<?php
include "header.inc";
$tbl = 'insurance';
$id = $_REQUEST["id"];
$dob1 = $_REQUEST["dob1"];
$regid = $_REQUEST["regid"];
$remoteip = $_SERVER["REMOTE_ADDR"];
include "mail.php";
if ($_POST["submit"] == "FIND") {
$enrollno = $_POST["enrollno"];
$rs = mysql_query("select * from registration where enrollNo='$enrollno'");
while ($o = mysql_fetch_object($rs)) {
$program = $o->courseName;
$fullname = $o->nameEnglish;
$dob = $o->dob;
$gender = $o->gender;
$bg = $o->bg;
$nationality = $o->nationality;
$category = $o->category;
$fathername = $o->fatherName;
$mothername = $o->motherName;
$address = $o->address1;
$city = $o->city1;
$state = $o->state1;
$pincode = $o->pin1;
$phone = $o->ph1;
$email = $o->email1;
}
}
if ($_POST["submit"] == "SAVE") {
$msg = "";
$enrollno = $_POST["enrollno"];
$program = $_POST["program"];
$fullname = $_POST["fullname"];
if (!$fullname) $msg = "Please enter your name";
$dob = $_POST["dob"];
if (!$dob) $msg = "Please enter your correct date of birth";
$gender = $_POST["gender"];
if (!$gender) $gender = 'Male';
$bg = $_POST["bg"];
$nationality = $_POST["nationality"];
if (!$nationality) $msg = "Please enter your nationality";
$category = $_POST["category"];
if (!$category) $category = 'GE';
$fathername = $_POST["fathername"];
if (!$fathername) $msg = "Please enter your father name";
$mothername = $_POST["mothername"];
if (!$mothername) $msg = "Please enter your mother name";
$address = $_POST["address"];
if (!$address) $msg = "Please enter your address";
$city = $_POST["city"];
if (!$city) $msg = "Please enter your city";
$pincode = $_POST["pincode"];
if (!$pincode) $msg = "Please enter pin code";
$state = $_POST["state"];
$phone = $_POST["phone"];
$mobile = $_POST["mobile"];
$email = $_POST["email"];
$comaddress = $_POST["comaddress"];
$comcity = $_POST["comcity"];
$compincode = $_POST["compincode"];
$comstate = $_POST["comstate"];
$compolicestation = $_POST["compolicestation"];
$comphone = $_POST["comphone"];
$commobile = $_POST["commobile"];
$comemail = $_POST["comemail"];
$fpgname = $_POST["fpgname"];
$relation = $_POST["relation"];
$fpgaddress = $_POST["fpgaddress"];
$fpgcity = $_POST["fpgcity"];
$fpgpincode = $_POST["fpgpincode"];
$fpgstate = $_POST["fpgstate"];
$fpgphone = $_POST["fpgphone"];
$fpgemail = $_POST["fpgemail"];
$maritalstatus = $_POST["maritalstatus"];
$spousename = $_POST["spousename"];
$spouseage = $_POST["spouseage"];
$spouseaddress = $_POST["spouseaddress"];
$spousecity = $_POST["spousecity"];
$spousepincode = $_POST["spousepincode"];
$spousestate = $_POST["spousestate"];
$spousephone = $_POST["spousephone"];
$spouseemail = $_POST["spouseemail"];
$children = $_POST["children"];
$fchildname = $_POST["fchildname"];
$fchildage = $_POST["fchildage"];
$fchildgender = $_POST["fchildgender"];
$fchildaddress = $_POST["fchildaddress"];
$fchildcity = $_POST["fchildcity"];
$fchildpincode = $_POST["fchildpincode"];
$fchildstate = $_POST["fchildstate"];
$fchildphone = $_POST["fchildphone"];
$fchildemail = $_POST["fchildemail"];
$schildname = $_POST["schildname"];
$schildage = $_POST["schildage"];
$schildgender = $_POST["schildgender"];
$schildaddress = $_POST["schildaddress"];
$schildcity = $_POST["schildcity"];
$schildpincode = $_POST["schildpincode"];
$schildstate = $_POST["schildstate"];
$schildphone = $_POST["schildphone"];
$schildemail = $_POST["schildemail"];
$pediseases1 = $_POST["pediseases1"];
$pediseases2 = $_POST["pediseases2"];
$pediseases3 = $_POST["pediseases3"];
$pediseases4 = $_POST["pediseases4"];
$pediseases5 = $_POST["pediseases5"];
$photo = $_FILES["photo"];
if ($msg) {
echo "<center><font size=4px color='red'>$msg</font></center>";
} else {
/*if (mysql_num_rows(mysql_query("select * from $tbl where id=$id"))) {
mysql_query ("update $tbl set erollno='$erollno',program='$program',fullname='$fullname', dob='$dob', gender='$gender', bg='$bg', nationality='$nationality', category='$category', fathername='$fathername', mothername='$mothername', address='$address', city='$city', pincode='$pincode', state='$state', phone='$phone', mobile='$mobile',email='$email', comaddress='$comaddress', comcity='$comcity', compincode='$compincode', comstate='$comstate', compolicestation='$compolicestation', comphone='$comphone', commobile='$commobile', comemail='$comemail', fpgname='$fpgname', fpgrelation='$relation', fpgaddress='$fpgaddress', fpgcity='$fpgcity', fpgpincode='$fpgpincode', fpgstate='$fpgstate', fpgphone='$fpgphone', fpgemail='$fpgemail', marritalstatus='$marritalstatus', spousename='$spousename', spouseage='$spouseage', spouseaddress='$spouseaddress', spousecity='$spousecity', spousepincode='$spousepincode', spousestate='$spousestate', spousephone='$spousephone', spouseemail='$spouseemail', childres='$children', fchildname='$fchildname', fchildage='$fchildage', fchildgender='$fchildgender', fchildaddress='$fchildaddress', fchildcity='$fchildcity', fchildpincode='$fchildpincode', fchildstate='$fchildstate', fchildphone='$fchildphone', fchildemail='$fchildemail', schildname='$schildname', schildage='$schildage', schildgender='$schildgender', schildaddress='$schildaddress', schildcity='$schildcity', schildpincode='$schildpincode', schildstate='$schildstate', schildphone='$schildphone', schildemail='$schildemail', pediseases1='$pediseases1', pediseases2='$pediseases2', pediseases3='$pediseases3', pediseases4='$pediseases4', pediseases5='$pediseases5', date_modification=now(), remoteip='$remoteip' where id=$id");
}else { */
mysql_query ("insert into $tbl (enrollno,program,fullname,dob,gender,bg,nationality,category,fathername,address,city,pincode,state,phone,mobile,email,comaddress,comcity,compincode,comstate,compolicestation,comphone,comemail,fpgname,relation,fpgaddress,fpgcity,fpgpincode,fpgstate,fpgphone,fpgemail,maritalstatus,spousename,spouseage,spouseaddress,spousecity,spousepincode,spousestate,spousephone,spouseemail,children,fchildname,fchildage,fchildgender,fchildaddress,fchildcity,fchildpincode,fchildstate,fchildphone,fchildemail,schildname,schildage,schildgender,schildaddress,schildcity,schildpincode,schildstate,schildphone,schildemail,pediseases1,pediseases2,pediseases3,pediseases4,pediseases5,photo,date_creation)
values ('$enrollno','$program','$fullname','$dob','$gender','$bg','$nationality','$category','$fathername','$address','$city','$pincode','$state','$phone','$mobile','$email','$comaddress','$comcity','$compincode','$comstate','$compolicestation','$comphone','$comemail','$fpgname','$relation','$fpgaddress','$fpgcity','$fpgpincode','$fpgstate','$fpgphone','$fpgemail','$maritalstatus','$spousename','$spouseage','$spouseaddress','$spousecity','$spousepincode','$spousestate','$spousephone','$spouseemail','$children','$fchildname','$fchildage','$fchildgender','$fchildaddress','$fchildcity','$fchildpincode','$fchildstate','$fchildphone','$fchildemail','$schildname','$schildage','$schildgender','$schildaddress','$schildcity','$schildpincode','$schildstate','$schildphone','$schildemail','$pediseases1','$pediseases2','$pediseases3','$pediseases4','$pediseases5','$photo',now())");
/* echo "insert into $tbl (enrollno,program,fullname,dob,gender,bg,nationality,category,fathername,address,city,pincode,state,phone,mobile,email,comaddress,comcity,compincode,comstate,compolicestation,comphone,comemail,fpgname,relation,fpgaddress,fpgcity,fpgpincode,fpgstate,fpgphone,fpgemail,maritalstatus,spousename,spouseage,spouseaddress,spousecity,spousepincode,spousestate,spousephone,spouseemail,children,fchildname,fchildage,fchildgender,fchildaddress,fchildcity,fchildpincode,fchildstate,fchildphone,fchildemail,schildname,schildage,schildgender,schildaddress,schildcity,schildpincode,schildstate,schildphone,schildemail,pediseases1,pediseases2,pediseases3,pediseases4,pediseases5,photo,date_creation)
values ('$enrollno','$program','$fullname','$dob','$gender','$bg','$nationality','$category','$fathername','$address','$city','$pincode','$state','$phone','$mobile','$email','$comaddress','$comcity','$compincode','$comstate','$compolicestation','$comphone','$comemail','$fpgname','$relation','$fpgaddress','$fpgcity','$fpgpincode','$fpgstate','$fpgphone','$fpgemail','$maritalstatus','$spousename','$spouseage','$spouseaddress','$spousecity','$spousepincode','$spousestate','$spousephone','$spouseemail','$children','$fchildname','$fchildage','$fchildgender','$fchildaddress','$fchildcity','$fchildpincode','$fchildstate','$fchildphone','$fchildemail','$schildname','$schildage','$schildgender','$schildaddress','$schildcity','$schildpincode','$schildstate','$schildphone','$schildemail','$pediseases1','$pediseases2','$pediseases3','$pediseases4','$pediseases5','$photo',now())";
*/
$id = mysql_insert_id();
}
if ($photo) {
$photo = upload_file($id);
mysql_query("update $tbl set photo='$photo' where id=$id");
}
//header("Location: appform.php?id=$id");
echo "<center><font color='red'><b>ID No. ".$id."</b></font></center>";
//}
}
echo "<input type='hidden' name='id' value='$id'>
<table width='100%'>
<tr><td><b>Details of the Student to be Insured</b>
<table>
<tr><td width=20%>1. Enrollment No. </td><td width=80%> <input type='text' name='enrollno' size='50' maxlength='50' value='$enrollno'>
<input type='submit' name='submit' value='FIND'>
<input type='button' name='new' value='NEW' onclick=\"window.location.href='index.php'\" />
</td></tr>
<!-- <tr><td width=20%>2. Program </td><td width=80%> <input type='text' onkeypress='return isCharacterKey(event)' name='program' size='50' maxlength='50' value='$program'></td></tr> -->
<tr><td>2. Program</td><td>
<select name='program'>";
$programs = array('B.Tech-IT','B.Tech-ECE','MBA','MSCLIS','M.Tech-BI','M.Tech-BME','M.Tech-CE','M.Tech-HCI','M.Tech-IS','M.Tech-MI','M.Tech-RO','M.Tech-SE','M.Tech-WCC','Ph.D');
foreach ($programs as $prg) {
echo "<option value='$prg'";
if ($program == $prg) echo " selected";
echo ">$prg</option>";
}
echo "</select>
</td></tr>
<tr><td width=20%>3. Full Name </td><td width=80%> <input type='text' onkeypress='return isCharacterKey(event)' name='fullname' size='50' maxlength='50' value='$fullname'></td></tr>
<tr><td>4. Date of Birth</td><td><input type='text' onkeypress='return isDateKey(event)' name='dob' size='25' maxlength='25' value='$dob'> (MM/DD/YYYY)
<!--<tr><td>4. Date of Birth</td><td><input type='text' onkeypress='return isNumberKey(event)' name='dd' size='2' maxlength='2' value='$dd'> (DD)
<input type='text' onkeypress='return isNumberKey(event)' name='mm' size='2' maxlength='2' value='$mm'> (MM)
<input type='text' onkeypress='return isNumberKey(event)' name='yy' size='4' maxlength='4' value='$yy'> (YYYY) -->";
//************************************************************************************************************
//Date in Dropdown list format - Prashant
/*
echo " <tr><td>4. Date of Birth</td><td>
<select name='dd'>";
$dates = array('01','02','03','04','05','06','07','08','09','10',
'11','12','13','14','15','16','17','18','19','20',
'21','22','23','24','25','26','27','28','29','30','31');
foreach ($dates as $dt) {
echo "<option value='$dt'";
if ($dt == $dd) echo " selected";
echo ">$dt</option>";
}
echo "</select> (DD)
<select name='mm'>";
$months = array('01','02','03','04','05','06','07','08','09','10','11','12');
foreach ($months as $mt) {
echo "<option value='$mt'";
if ($mt == $mm) echo " selected";
echo ">$mt</option>";
}
echo "</select> (MM)
<select name='yy'>";
$years = array('1960','1961','1962','1963','1964','1965','1966','1967','1968','1969',
'1970','1971','1972','1973','1974','1975','1976','1977','1978','1979',
'1980','1981','1982','1983','1984','1985','1986','1987','1988','1989',
'1990','1991','1992','1993','1994','1995','1996','1997','1998','1999',
'2000');
foreach ($years as $yr) {
echo "<option value='$yr'";
if ($yr == $yy) echo " selected";
echo ">$yr</option>";
}
echo "</select> (YYYY)
</td></tr>
";
*/
//*************************************************************************************************************
echo "</td></tr>
<tr><td>5. Gender </td><td>";
$genders = array("Male","Female");
foreach ($genders as $gen) {
echo "<input type='radio' name='gender' value='$gen'";
if ($gen == $gender) echo " checked";
echo "> $gen ";
}
echo "
</td></tr>
<!-- <tr><td>6. Blood Group</td><td><input type='text' name='bg' size='5' maxlength='5' value='$bg'></td></tr> -->
<tr><td>6. Blood Group</td><td>
<select name='bg'>";
$bgps = array('NAV','O+','A+','B+','AB+','O-','A-','B-','AB-');
foreach ($bgps as $bgp) {
echo "<option value='$bgp'";
if ($bg == $bgp) echo " selected";
echo ">$bgp</option>";
}
echo "</select>
</td></tr>
<tr><td>7. Nationality</td><td><input type='text' onkeypress='return isCharacterKey(event)' name='nationality' size='50' maxlength='150' value='$nationality'></td></tr>
<tr><td valign='top'>8. Category</td><td>";
$categories = array("General","OBC","SC","ST","PH","MN","SN");
foreach ($categories as $cat) {
echo "<input type='radio' name='category' value='$cat'";
if ($cat == $category) echo " checked";
echo "/> $cat ";
}
echo "<br>(General, OBC=Other Backward Class, SC=Schedule Cast, <br>
ST=Schedule Tribe, PH=Physically Handicapped, MN=Minority, SN=Sponsored )
</td></tr>
<tr><td>9. Father Name</td><td><input type='text' onkeypress='return isCharacterKey(event)' name='fathername' size='50' maxlength='150' value='$fathername'></td></tr>
<tr><td>10. Mother Name</td><td><input type='text' onkeypress='return isCharacterKey(event)' name='mothername' size='50' maxlength='150' value='$mothername'></td></tr>
<tr><td>11. Address </td><td><textarea name='address' rows='3' cols='50' maxlength='150' value='$address' >$address</textarea></td></tr>
<tr><td>10. City</td><td><input type='text' onkeypress='return isCharacterKey(event)' name='city' size='50' maxlength='150' value='$city'></td></tr>
<tr><td>11. State</td><td>
<select name='state'>";
$states = array('Not Available','Andaman & Nicobar','Andhra Pradesh','Arunachal Pradesh','Assam','Bihar','Chandigarh',
'Chhattisgarh','Dadra & Nagar Haveli','Lakshadweep','Madhya Pradesh','Maharashtra','Manipur','Meghalaya','Mizoram',
'Nagaland','New Delhi','Orissa','Daman & Diu','Goa','Gujarat','Haryana','Himachal Pradesh','Jammu & Kashmir',
'Jharkhand','Karnataka','Kerala','Puducherry','Punjab','Rajasthan','Sikkim','Tamil Nadu','Tripura',
'Uttar Pradesh','Uttarakhand','West Bengal');
foreach ($states as $stat) {
echo "<option value='$stat'";
if ($stat == $state) echo " selected";
echo ">$stat</option>";
}
echo "</select>
</td></tr>
<tr><td>13. Pin Code </td><td> <input type='text' onkeypress='return isNumberKey(event)' name='pincode' size='10' maxlength='6' value='$pincode'>
</td></tr><tr><td>14. Phone No. </td><td> <input type='text' name='phone' size='50' maxlength='50' value='$phone'>
</td></tr><tr><td>15. Mobile No. </td><td> <input type='text' name='mobile' size='50' maxlength='50' value='$mobile'>
</td></tr><tr><td>16. Email </td><td> <input type='text' name='email' size='50' maxlength='50' value='$email'>
</td></tr>
</table>
</td><td valign=top>
";
if (!$photo){
echo "<img src='user_thumb_large.jpg' height=100 width=100 /><br>";}
else{
echo "<img src='photos/$id.jpg' height=100 width=100 /><br>";}
echo"17. Upload your photograph <sup>*</sup> (.jpg file only)<br>
<input type='file' name='photo' size='30' value='$photo' /> <br><br>
<hr>
<b>Complete Address of NORMAL RESIDENCE of the Enrolled Student</b>
<table>
<tr><td>18. Address for Correspondance</td><td><textarea name='comaddress' rows='3' cols='50' maxlength='150' value='$comaddress' >$comaddress</textarea></td></tr>
<tr><td>19. City</td><td><input type='text' onkeypress='return isCharacterKey(event)' name='comcity' size='50' maxlength='150' value='$comcity'>$comcity</td></tr>
<tr><td>20. State</td><td>
<select name='comstate'>";
$states = array('Not Available','Andaman & Nicobar','Andhra Pradesh','Arunachal Pradesh','Assam','Bihar','Chandigarh',
'Chhattisgarh','Dadra & Nagar Haveli','Lakshadweep','Madhya Pradesh','Maharashtra','Manipur','Meghalaya','Mizoram',
'Nagaland','New Delhi','Orissa','Daman & Diu','Goa','Gujarat','Haryana','Himachal Pradesh','Jammu & Kashmir',
'Jharkhand','Karnataka','Kerala','Puducherry','Punjab','Rajasthan','Sikkim','Tamil Nadu','Tripura',
'Uttar Pradesh','Uttarakhand','West Bengal');
foreach ($states as $stat) {
echo "<option value='$stat'";
if ($stat == $state) echo " selected";
echo ">$stat</option>";
}
echo "</select>
</td></tr>
<tr><td>21. Pin Code </td><td> <input type='text' onkeypress='return isNumberKey(event)' name='compincode' size='10' maxlength='6' value='$compincode'>
<tr><td>22. Police Station </td><td> <input type='text' onkeypress='return isCharacterKey(event)' name='compolicestation' size='50' maxlength='50' value='$compolicestation'>
</td></tr><tr><td>23. Contact No. </td><td> <input type='text' name='comphone' size='50' maxlength='50' value='$comphone'>
</td></tr><tr><td>24. Email </td><td> <input type='text' name='comemail' size='50' maxlength='50' value='$comemail'>
</td></tr>
<tr><td> </td></tr>
</table>
</td></tr>
<tr><td>
<hr><b>Details of the FEE PAYING Parent/guardian of the Enrolled Student</b>
<table>
<tr><td width=20%>25. Full Name </td><td width=80%> <input type='text' onkeypress='return isCharacterKey(event)' name='fpgname' size='50' maxlength='50' value='$fpgname'></td></tr>
<tr><td width=20%>26. Relation </td><td width=80%> <input type='text' onkeypress='return isCharacterKey(event)' name='relation' size='50' maxlength='50' value='$relation'></td></tr>
<tr><td>27. Address </td><td><textarea name='fpgaddress' rows='3' cols='50' maxlength='150' value='$fpgaddress' >$fpgaddress</textarea></td></tr>
<tr><td>28. City</td><td><input type='text' onkeypress='return isCharacterKey(event)' name='fpgcity' size='50' maxlength='150' value='$fpgcity'>$fpgcity</td></tr>
<tr><td>29. State</td><td>
<select name='fpgstate'>";
$states = array('Not Available','Andaman & Nicobar','Andhra Pradesh','Arunachal Pradesh','Assam','Bihar','Chandigarh',
'Chhattisgarh','Dadra & Nagar Haveli','Lakshadweep','Madhya Pradesh','Maharashtra','Manipur','Meghalaya','Mizoram',
'Nagaland','New Delhi','Orissa','Daman & Diu','Goa','Gujarat','Haryana','Himachal Pradesh','Jammu & Kashmir',
'Jharkhand','Karnataka','Kerala','Puducherry','Punjab','Rajasthan','Sikkim','Tamil Nadu','Tripura',
'Uttar Pradesh','Uttarakhand','West Bengal');
foreach ($states as $stat) {
echo "<option value='$stat'";
if ($stat == $fpgstate) echo " selected";
echo ">$stat</option>";
}
echo "</select>
</td></tr>
<tr><td>30. Pin Code </td><td> <input type='text' onkeypress='return isNumberKey(event)' name='fpgpincode' size='10' maxlength='6' value='$fpgpincode'>
</td></tr><tr><td>31. Contact No. </td><td> <input type='text' name='fpgphone' size='50' maxlength='50' value='$fpgphone'>
</td></tr><tr><td>32. Email </td><td> <input type='text' name='fpgemail' size='50' maxlength='50' value='$fpgemail'>
</td></tr>
</table>
</td><td>
<hr>
<table>
<tr><td colspan=2>33. (a) Marital Status";
$maritalstatus = array("Married","UnMarried");
foreach ($maritalstatus as $mstat) {
echo "<input type='radio' name='maritalstatus' value='$mstat'";
if ($mstat == $maritalstatus) echo " checked";
echo "> $mstat ";
}
echo "</td></tr>
<tr><td colspan=2>(b) In Case 'Married', then pl. provide the following:</td></tr>
<tr><td width=20%>34. Name of Spouse</td><td width=80%> <input type='text' onkeypress='return isCharacterKey(event)' name='spousename' size='50' maxlength='50' value='$spousename'></td></tr>
<tr><td width=20%>35. Age</td><td width=80%> <input type='text' onkeypress='return isNumberKey(event)' name='spouseage' size='50' maxlength='50' value='$spouseage'></td></tr>
<tr><td>36. Address </td><td><textarea name='spouseaddress' rows='3' cols='50' maxlength='150' value='$spouseaddress' >$spouseaddress</textarea></td></tr>
<tr><td>37. City</td><td><input type='text' onkeypress='return isCharacterKey(event)' name='spousecity' size='50' maxlength='150' value='$spousecity'>$spousecity</td></tr>
<tr><td>38. State</td><td>
<select name='spousestate'>";
$states = array('Not Available','Andaman & Nicobar','Andhra Pradesh','Arunachal Pradesh','Assam','Bihar','Chandigarh',
'Chhattisgarh','Dadra & Nagar Haveli','Lakshadweep','Madhya Pradesh','Maharashtra','Manipur','Meghalaya','Mizoram',
'Nagaland','New Delhi','Orissa','Daman & Diu','Goa','Gujarat','Haryana','Himachal Pradesh','Jammu & Kashmir',
'Jharkhand','Karnataka','Kerala','Puducherry','Punjab','Rajasthan','Sikkim','Tamil Nadu','Tripura',
'Uttar Pradesh','Uttarakhand','West Bengal');
foreach ($states as $stat) {
echo "<option value='$stat'";
if ($stat == $spousestate) echo " selected";
echo ">$stat</option>";
}
echo "</select>
</td></tr>
<tr><td>39. Pin Code </td><td> <input type='text' onkeypress='return isNumberKey(event)' name='spousepincode' size='10' maxlength='6' value='$spousepincode'>
</td></tr><tr><td>40. Contact No. </td><td> <input type='text' name='spousephone' size='50' maxlength='50' value='$spousephone'>
</td></tr><tr><td>41. Email </td><td> <input type='text' name='spouseemail' size='50' maxlength='50' value='$spouseemail'>
</td></tr>
</table>
</td></tr>
<tr><td colspan=2><hr><b>42. Do you have dependent Children</b>
<input type='radio' name='children' value='yes'> Yes
<input type='radio' name='children' value='no' checked> No
</td></tr>
<tr><td>
<hr>
<b>First Child Details [Elder Child] </b>
<table>
<tr><td width=20%>43. Name </td><td width=80%> <input type='text' onkeypress='return isCharacterKey(event)' name='fchildname' size='50' maxlength='50' value='$fchildname'></td></tr>
<tr><td width=20%>44. Age </td><td width=80%> <input type='text' onkeypress='return isNumberKey(event)' name='fchildage' size='50' maxlength='50' value='$fchildage'></td></tr>
<tr><td>45. Gender </td><td>";
$genders = array("Male","Female");
foreach ($genders as $gen) {
echo "<input type='radio' name='fchildgender' value='$gen'";
if ($gen == $fchildgender) echo " checked";
echo "> $gen ";
}
echo "
<tr><td>46. Address</td><td><textarea name='fchildaddress' rows='3' cols='50' maxlength='150' value='$fchildaddress' >$fchildaddress</textarea></td></tr>
<tr><td>47. City</td><td><input type='text' onkeypress='return isCharacterKey(event)' name='fchildcity' size='50' maxlength='150' value='$fchildcity'>$fchildcity</td></tr>
<tr><td>48. State</td><td>
<select name='fchildstate'>";
$states = array('Not Available','Andaman & Nicobar','Andhra Pradesh','Arunachal Pradesh','Assam','Bihar','Chandigarh',
'Chhattisgarh','Dadra & Nagar Haveli','Lakshadweep','Madhya Pradesh','Maharashtra','Manipur','Meghalaya','Mizoram',
'Nagaland','New Delhi','Orissa','Daman & Diu','Goa','Gujarat','Haryana','Himachal Pradesh','Jammu & Kashmir',
'Jharkhand','Karnataka','Kerala','Puducherry','Punjab','Rajasthan','Sikkim','Tamil Nadu','Tripura',
'Uttar Pradesh','Uttarakhand','West Bengal');
foreach ($states as $stat) {
echo "<option value='$stat'";
if ($stat == $fchildstate) echo " selected";
echo ">$stat</option>";
}
echo "</select>
</td></tr>
<tr><td>49. Pin Code </td><td> <input type='text' onkeypress='return isNumberKey(event)' name='fchildpincode' size='10' maxlength='6' value='$fchildpincode'>
</td></tr><tr><td>50. Contact No. </td><td> <input type='text' name='fchildphone' size='50' maxlength='50' value='$fchildphone'>
</td></tr><tr><td>51. Email </td><td> <input type='text' name='fchildemail' size='50' maxlength='50' value='$fchildemail'>
</td></tr>
</table>
</td><td>
<hr>
<b>Second Child Details [Younger Child] </b>
<table>
<tr><td width=20%>52. Name </td><td width=80%> <input type='text' onkeypress='return isCharacterKey(event)' name='schildname' size='50' maxlength='50' value='$schildname'></td></tr>
<tr><td width=20%>53. Age </td><td width=80%> <input type='text' onkeypress='return isNumberKey(event)' name='schildage' size='50' maxlength='50' value='$schildage'></td></tr>
<tr><td>54. Gender </td><td>";
$genders = array("Male","Female");
foreach ($genders as $gen) {
echo "<input type='radio' name='schildgender' value='$gen'";
if ($gen == $schildgender) echo " checked";
echo "> $gen ";
}
echo "
<tr><td>55. Address </td><td><textarea name='schildaddress' rows='3' cols='50' maxlength='150' value='$schildaddress' >$schildaddress</textarea></td></tr>
<tr><td>56. City</td><td><input type='text' onkeypress='return isCharacterKey(event)' name='schildcity' size='50' maxlength='150' value='$schildcity'>$schildcity</td></tr>
<tr><td>57. State</td><td>
<select name='schildstate'>";
$states = array('Not Available','Andaman & Nicobar','Andhra Pradesh','Arunachal Pradesh','Assam','Bihar','Chandigarh',
'Chhattisgarh','Dadra & Nagar Haveli','Lakshadweep','Madhya Pradesh','Maharashtra','Manipur','Meghalaya','Mizoram',
'Nagaland','New Delhi','Orissa','Daman & Diu','Goa','Gujarat','Haryana','Himachal Pradesh','Jammu & Kashmir',
'Jharkhand','Karnataka','Kerala','Puducherry','Punjab','Rajasthan','Sikkim','Tamil Nadu','Tripura',
'Uttar Pradesh','Uttarakhand','West Bengal');
foreach ($states as $stat) {
echo "<option value='$stat'";
if ($stat == $schildstate) echo " selected";
echo ">$stat</option>";
}
echo "</select>
</td></tr>
<tr><td>58. Pin Code </td><td> <input type='text' onkeypress='return isNumberKey(event)' name='schildpincode' size='10' maxlength='6' value='$schildpincode'>
</td></tr><tr><td>59. Contact No. </td><td> <input type='text' name='schildphone' size='50' maxlength='50' value='$schildphone'>
</td></tr><tr><td>60. Email </td><td> <input type='text' name='schildemail' size='50' maxlength='50' value='$schildemail'>
</td></tr>
</table>
</td></tr>
<tr><td colspan=2>
<hr>
<b>Pre Existing Diseases*, at the time of admission into the Institute.</b><br>
<table>
<tr><td>61. </td><td><input type='text' name='pediseases1' size='100' maxlength='100' value='$pediseases1' /></td></tr>
<tr><td>62. </td><td><input type='text' name='pediseases2' size='100' maxlength='100' value='$pediseases2' /></td></tr>
<tr><td>63. </td><td><input type='text' name='pediseases3' size='100' maxlength='100' value='$pediseases3' /></td></tr>
<tr><td>64. </td><td><input type='text' name='pediseases4' size='100' maxlength='100' value='$pediseases4' /></td></tr>
<tr><td>65. </td><td><input type='text' name='pediseases5' size='100' maxlength='100' value='$pediseases5' /></td></tr>
</table>
</td></tr>
<!--************************************************************************************************************* -->
<tr><td colspan=2><br>
<center><input type='submit' name='submit' value='SAVE'></center>";
echo "</td></tr></table>
";
?>
<br>
* Scanned copy of Photograph can be uploaded on the online application form.<br>
<?php
include "footer.inc";
?>