I'm also having this issue, with an approximately 65-item form.
I created my form outside of Chronoforms to format/style it the way I wanted, and then pasted the code into the "Form Code" tab for the appropriate form.
I created a DB table using Chronoforms, avoiding any dashes. I do use an underscore in the table name.
The form name also has no dashes in the name.
I noticed some of the form-classes and names (such as class="radio radio radio validate-one-required") which were created when I initially used the form wizard to create part of the form, do have dashes in them. Since the class has spaces in it, I'm not sure it's valid although BBEdit validates it fine.
I set "Load Chronoforms CSS/JS Files?" to "No".
Here's what I've tried so far:
renamed the DB to avoid dashes.
Toggled the Load Chronoforms CSS/JS Files to No, and Yes.
Tried an E-mail Setup with and without Dynamic To fields.
None of these variables seem to make a difference.
I AM able to fill out the form and the form data IS saved to the DB table. The only thing standing between success and failure at this moment is being able to send out a confirmation e-mail with the form data to the form user and an administrator.
Code for the form is attached, cut from the 'Form Code" viewing box:
<h1>ENROLLMENT APPLICATION FOR 2009–2010</h1>
<p>Please complete ALL information requested, as it is required by the State of Colorado. Incomplete applications will be returned and may lose their placement order when filling classes.</p>
<p><strong>All information contained in this form is strictly confidential and for school use only. A roster of student information by class (name, parents, address, and phone number) will be distributed to the other members of the cooperative at
the beginning of the school year. By submitting this application, I acknowledge that this information will be used in
this manner.</strong> If you do not wish to be included on the roster for privacy reasons, please let the enrollment chairperson
know of your wishes at the time of application. All information in this application can be changed as necessary.</p>
<label style="width: 300px;">Application Date (today's date): mm/dd/yyyy</label>
<input class="cf_inputbox required" maxlength="150" size="10" id="text_1" name="application_date" type="text" />
<fieldset>
<legend>Child Information</legend>
<h3>Name and Birthdate</h3>
<ol>
<li> <label>Child's First Name</label>
<input class="cf_inputbox required" maxlength="150" size="30" id="text_2" name="child_first_name" type="text" /></li>
<li><label>Child's Middle Name</label>
<input class="cf_inputbox required" maxlength="150" size="10" id="text_3" name="child_middle_name" type="text" /> </li>
<li><label>Child's Last Name</label>
<input class="cf_inputbox required" maxlength="150" size="30" id="text_4" name="child_last_name" type="text" /></li>
<li><label>Birth Month</label>
<select class="cf_inputbox validate-selection" id="select_1" size="1" name="birth_month">
<option value="">Choose Option</option>
<option value="January">January</option>
<option value="February">February</option>
<option value="March">March</option>
<option value="April">April</option>
<option value="May">May</option>
<option value="June">June</option>
<option value="July">July</option>
<option value="August">August</option>
<option value="September">September</option>
<option value="October">October</option>
<option value="November">November</option>
<option value="December">December</option>
</select></li>
<li><label>Birth Date</label>
<select class="cf_inputbox validate-selection" id="select_2" size="1" name="birth_date">
<option value="">Choose Option</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select></li>
<li><label>Birth Year</label>
<select class="cf_inputbox validate-selection" id="select_3" size="1" name="birth_year">
<option value="">Choose Option</option>
<option value="2004">2004</option>
<option value="2005">2005</option>
<option value="2006">2006</option>
<option value="2007">2007</option>
<option value="2008">2008</option>
<option value="2009">2009</option>
<option value="2010">2010</option>
<option value="2011">2011</option>
<option value="2012">2012</option>
<option value="2013">2013</option>
</select></li>
<li>
<label>Gender</label>
<input value="Male" class="radio radio radio radio validate-one-required" id="Male" name="Gender" type="radio" value="male" />
<label for="Male" class="radio_label">Male</label>
<input value="Female" class="radio radio radio radio validate-one-required" id="Female" name="Gender" type="radio" value="female" />
<label for="Female" class="radio_label">Female</label></li>
</ol>
<h3>Child's Primary Address</h3>
<ol>
<li> <label>Street</label>
<textarea class="cf_inputbox required" rows="2" id="text_5" cols="30" name="child_street"></textarea></li>
<li><label>City</label>
<input class="cf_inputbox required" maxlength="150" size="30" id="text_6" name="child_city" type="text" /></li>
<li><label>State</label>
<select class="cf_inputbox validate-selection" id="select_4" size="1" name="child_state">
<option value="">Choose Option</option>
<option value="Alabama - AL">Alabama - AL</option>
<option value="Alaska - AK">Alaska - AK</option>
<option value="American Samoa - AS">American Samoa - AS</option>
<option value="Arizona - AZ">Arizona - AZ</option>
<option value="Arkansas - AR">Arkansas - AR</option>
<option value="California - CA">California - CA</option>
<option selected="selected" value="Colorado - CO">Colorado - CO</option>
<option value="Connecticut - CT">Connecticut - CT</option>
<option value="Delaware - DE">Delaware - DE</option>
<option value="District of Columbia - DC">District of Columbia - DC</option>
<option value="Federated States of Micronesia* - FM">Federated States of Micronesia* - FM</option>
<option value="Florida - FL">Florida - FL</option>
<option value="Georgia - GA">Georgia - GA</option>
<option value="Guam - GU">Guam - GU</option>
<option value="Hawaii - HI">Hawaii - HI</option>
<option value="Idaho - ID">Idaho - ID</option>
<option value="Illinois - IL">Illinois - IL</option>
<option value="Indiana - IN">Indiana - IN</option>
<option value="Iowa - IA">Iowa - IA</option>
<option value="Kansas - KS">Kansas - KS</option>
<option value="Kentucky - KY">Kentucky - KY</option>
<option value="Louisiana - LA">Louisiana - LA</option>
<option value="Maine - ME">Maine - ME</option>
<option value="Marshall Islands* - MH">Marshall Islands* - MH</option>
<option value="Maryland - MD">Maryland - MD</option>
<option value="Massachusetts - MA">Massachusetts - MA</option>
<option value="Michigan - MI">Michigan - MI</option>
<option value="Minnesota - MN">Minnesota - MN</option>
<option value="Mississippi - MS">Mississippi - MS</option>
<option value="Missouri - MO">Missouri - MO</option>
<option value="Montana - MT">Montana - MT</option>
<option value="Nebraska - NE">Nebraska - NE</option>
<option value="Nevada - NV">Nevada - NV</option>
<option value="New Hampshire - NH">New Hampshire - NH</option>
<option value="New Jersey - NJ">New Jersey - NJ</option>
<option value="New Mexico - NM">New Mexico - NM</option>
<option value="New York - NY">New York - NY</option>
<option value="North Carolina - NC">North Carolina - NC</option>
<option value="North Dakota - ND">North Dakota - ND</option>
<option value="Northern Mariana Islands - MP">Northern Mariana Islands - MP</option>
<option value="Ohio - OH">Ohio - OH</option>
<option value="Oklahoma - OK">Oklahoma - OK</option>
<option value="Oregon - OR">Oregon - OR</option>
<option value="Palau* - PW">Palau* - PW</option>
<option value="Pennsylvania - PA">Pennsylvania - PA</option>
<option value="Puerto Rico - PR">Puerto Rico - PR</option>
<option value="Rhode Island - RI">Rhode Island - RI</option>
<option value="South Carolina - SC">South Carolina - SC</option>
<option value="South Dakota - SD">South Dakota - SD</option>
<option value="Tennessee - TN">Tennessee - TN</option>
<option value="Texas - TX">Texas - TX</option>
<option value="Utah - UT">Utah - UT</option>
<option value="Vermont - VT">Vermont - VT</option>
<option value="Virgin Island - VI">Virgin Island - VI</option>
<option value="Virginia - VA">Virginia - VA</option>
<option value="Washington - WA">Washington - WA</option>
<option value="West Virginia - WV">West Virginia - WV</option>
<option value="Wisconsin - WI">Wisconsin - WI</option>
<option value="Wyoming - WY">Wyoming - WY</option>
</select></li>
<li><label>ZIP</label>
<input class="cf_inputbox required" maxlength="10" size="10" id="text_7" name="child_zip" type="text" /></li>
<li><label>Phone</label>
<input class="cf_inputbox required" maxlength="150" size="30" id="text_8" name="child_phone" type="text" /></li>
</ol>
</fieldset>
<fieldset>
<legend>Class Selection</legend>
<ol>
<li>
<label style="width: 250px;">Select the class requested for your child's enrollment:</label>
<input value="Tadpoles (Tuesday)" class="radio radio radio validate-one-required" id="Tadpoles_Tuesday" name="class_requested" type="radio" />
<label for="Tadpoles_Tuesday" class="radio_label">Tadpoles (Tuesday)</label>
</li>
<li><input value="Tadpoles (Thursday)" class="radio radio radio validate-one-required" id="Tadpoles_Thursday" name="class_requested" type="radio" />
<label for="Tadpoles_Thursday" class="radio_label">Tadpoles (Thursday)</label>
</li>
<li><input value="Tadpoles (January Start)" class="radio radio radio validate-one-required" id="Tadpoles_JanuaryStart" name="class_requested" type="radio" />
<label for="Tadpoles_JanuaryStart" class="radio_label">Tadpoles (January Start)</label>
</li>
<li><input value="Polliwogs (Morning)" class="radio radio radio validate-one-required" id="Polliwogs_Morning" name="class_requested" type="radio" />
<label for="Polliwogs_Morning" class="radio_label">Polliwogs (Morning)</label>
</li>
<li><input value="Polliwogs (Afternoon)" class="radio radio radio validate-one-required" id="Polliwogs_Afternoon" name="class_requested" type="radio" />
<label for="Polliwogs_Afternoon" class="radio_label">Polliwogs (Afternoon)</label>
</li>
<li><input value="Frogs" class="radio radio radio validate-one-required" id="Frogs" name="class_requested" type="radio" />
<label for="Frogs" class="radio_label">Frogs</label>
</li>
</ol>
</fieldset>
<fieldset>
<legend>Parent/Guardian Information</legend>
<h3>Primary Parent/Guardian</h3>
<ol>
<li><label>First Name</label>
<input class="cf_inputbox required" maxlength="150" size="30" id="text_9" name="primary_first_name" type="text" />
</li>
<li><label>Last Name</label>
<input class="cf_inputbox required" maxlength="150" size="30" id="text_10" name="primary_last_name" type="text" />
</li></ol>
<h4>Address</h4>
<ol>
<li><label>Same as Child's Primary Address?</label>
<input value="Yes" class="radio radio" id="Yes" name="Primary_Address_Same_as_Child_Address" type="radio" /><label for="Yes" class="radio_label">Yes</label>
</li>
<li><input value="No; my address is listed below:" class="radio radio" id="No_my_address_is_listed_below" name="Primary_Address_Same_as_Child_Address" type="radio" />
<label for="No_my_address_is_listed_below" class="radio_label">No; my address is listed below:</label>
</li>
<li><label>Street</label>
<textarea class="cf_inputbox" rows="2" id="text_11" cols="30" name="primary_street_address"></textarea>
</li>
<li><label>City</label>
<input class="cf_inputbox" maxlength="150" size="30" id="text_12" name="primary_city" type="text" />
</li>
<li><label>State</label>
<select class="cf_inputbox" id="select_5" size="1" name="primary_state">
<option value="">Choose Option</option>
<option value="Alabama - AL">Alabama - AL</option>
<option value="Alaska - AK">Alaska - AK</option>
<option value="American Samoa - AS">American Samoa - AS</option>
<option value="Arizona - AZ">Arizona - AZ</option>
<option value="Arkansas - AR">Arkansas - AR</option>
<option value="California - CA">California - CA</option>
<option selected="selected" value="Colorado - CO">Colorado - CO</option>
<option value="Connecticut - CT">Connecticut - CT</option>
<option value="Delaware - DE">Delaware - DE</option>
<option value="District of Columbia - DC">District of Columbia - DC</option>
<option value="Federated States of Micronesia* - FM">Federated States of Micronesia* - FM</option>
<option value="Florida - FL">Florida - FL</option>
<option value="Georgia - GA">Georgia - GA</option>
<option value="Guam - GU">Guam - GU</option>
<option value="Hawaii - HI">Hawaii - HI</option>
<option value="Idaho - ID">Idaho - ID</option>
<option value="Illinois - IL">Illinois - IL</option>
<option value="Indiana - IN">Indiana - IN</option>
<option value="Iowa - IA">Iowa - IA</option>
<option value="Kansas - KS">Kansas - KS</option>
<option value="Kentucky - KY">Kentucky - KY</option>
<option value="Louisiana - LA">Louisiana - LA</option>
<option value="Maine - ME">Maine - ME</option>
<option value="Marshall Islands* - MH">Marshall Islands* - MH</option>
<option value="Maryland - MD">Maryland - MD</option>
<option value="Massachusetts - MA">Massachusetts - MA</option>
<option value="Michigan - MI">Michigan - MI</option>
<option value="Minnesota - MN">Minnesota - MN</option>
<option value="Mississippi - MS">Mississippi - MS</option>
<option value="Missouri - MO">Missouri - MO</option>
<option value="Montana - MT">Montana - MT</option>
<option value="Nebraska - NE">Nebraska - NE</option>
<option value="Nevada - NV">Nevada - NV</option>
<option value="New Hampshire - NH">New Hampshire - NH</option>
<option value="New Jersey - NJ">New Jersey - NJ</option>
<option value="New Mexico - NM">New Mexico - NM</option>
<option value="New York - NY">New York - NY</option>
<option value="North Carolina - NC">North Carolina - NC</option>
<option value="North Dakota - ND">North Dakota - ND</option>
<option value="Northern Mariana Islands - MP">Northern Mariana Islands - MP</option>
<option value="Ohio - OH">Ohio - OH</option>
<option value="Oklahoma - OK">Oklahoma - OK</option>
<option value="Oregon - OR">Oregon - OR</option>
<option value="Palau* - PW">Palau* - PW</option>
<option value="Pennsylvania - PA">Pennsylvania - PA</option>
<option value="Puerto Rico - PR">Puerto Rico - PR</option>
<option value="Rhode Island - RI">Rhode Island - RI</option>
<option value="South Carolina - SC">South Carolina - SC</option>
<option value="South Dakota - SD">South Dakota - SD</option>
<option value="Tennessee - TN">Tennessee - TN</option>
<option value="Texas - TX">Texas - TX</option>
<option value="Utah - UT">Utah - UT</option>
<option value="Vermont - VT">Vermont - VT</option>
<option value="Virgin Island - VI">Virgin Island - VI</option>
<option value="Virginia - VA">Virginia - VA</option>
<option value="Washington - WA">Washington - WA</option>
<option value="West Virginia - WV">West Virginia - WV</option>
<option value="Wisconsin - WI">Wisconsin - WI</option>
<option value="Wyoming - WY">Wyoming - WY</option>
</select></li>
<li><label>ZIP</label>
<input class="cf_inputbox" maxlength="150" size="10" id="text_13" name="primary_zip" type="text" /></li></ol>
<h4>Phone and E-mail</h4>
<ol>
<li><label>Home Phone</label>
<input class="cf_inputbox" maxlength="150" size="30" id="text_14" name="primary_home_phone" type="text" />
</li>
<li><label>Mobile Phone</label>
<input class="cf_inputbox" maxlength="150" size="30" id="text_15" name="primary_mobile_phone" type="text" />
</li>
<li><label>Work Phone</label>
<input class="cf_inputbox" maxlength="150" size="30" id="text_16" name="primary_work_phone" type="text" />
</li>
<li><label>E-mail address</label>
<input class="cf_inputbox validate-email" maxlength="150" size="30" id="text_17" name="primary_email" type="text" />
</li></ol>
<h4>Employer Information</h4>
<ol>
<li><label>Occupation</label>
<input class="cf_inputbox" maxlength="150" size="45" id="text_18" </li>
<li><label>Employer</label>
<input class="cf_inputbox" maxlength="150" size="45" id="text_19" name="primary_employer" type="text" />
</li>
<li><label>Business Street Address</label>
<textarea class="cf_inputbox" rows="2" id="text_20" cols="30" name="primary_business_street"></textarea>
</li>
<li><label>Business City</label>
<input class="cf_inputbox" maxlength="150" size="30" id="text_21" name="primary_business_city" type="text" />
</li>
<li><label>Business State</label>
<select class="cf_inputbox" id="select_6" size="1" name="primary_business_state">
<option value="">Choose Option</option>
<!--redacted to meet message character limit-->
</select>
</li>
<li><label>Business ZIP</label>
<input class="cf_inputbox" maxlength="150" size="10" id="text_22" name="primary_business_zip" type="text" />
</li></ol>
<h3>Second Parent/Guardian</h3>
<ol>
<li><label>First Name</label>
<input class="cf_inputbox required" maxlength="150" size="30" id="text_23" name="secondary_first_name" type="text" />
</li>
<li><label>Last Name</label>
<input class="cf_inputbox required" maxlength="150" size="30" id="text_24" name="secondary_last_name" type="text" />
</li></ol>
<h4>Address</h4>
<ol>
<li><label>Same as Child's Primary Address?</label>
<input value="Yes" class="radio radio" id="same_addr_as_child" name="Primary_Address_NOT_Same_as_Child_Address" type="radio" />
<label for="Yes" class="radio_label">Yes</label>
</li>
<li><input value="No; my address is listed below:" class="radio radio" id="different_addr_than_child" name="Primary_Address_NOT_Same_as_Child_Address" type="radio" />
<label for="different_addr_than_child" class="radio_label">No; my address is listed below:</label>
<label>Street</label>
<textarea class="cf_inputbox" rows="2" id="text_25" cols="30" name="secondary_street_address"></textarea></li>
<li><label>City</label>
<input class="cf_inputbox" maxlength="150" size="30" id="text_26" name="secondary_city" type="text" /></li>
<li><label>State</label>
<select class="cf_inputbox" id="select_7" size="1" name="secondary_state">
<option value="">Choose Option</option>
<option value="Alabama - AL">Alabama - AL</option>
<option value="Alaska - AK">Alaska - AK</option>
<option value="American Samoa - AS">American Samoa - AS</option>
<option value="Arizona - AZ">Arizona - AZ</option>
<option value="Arkansas - AR">Arkansas - AR</option>
<option value="California - CA">California - CA</option>
<option selected="selected" value="Colorado - CO">Colorado - CO</option>
<option value="Connecticut - CT">Connecticut - CT</option>
<option value="Delaware - DE">Delaware - DE</option>
<option value="District of Columbia - DC">District of Columbia - DC</option>
<option value="Federated States of Micronesia* - FM">Federated States of Micronesia* - FM</option>
<option value="Florida - FL">Florida - FL</option>
<option value="Georgia - GA">Georgia - GA</option>
<option value="Guam - GU">Guam - GU</option>
<option value="Hawaii - HI">Hawaii - HI</option>
<option value="Idaho - ID">Idaho - ID</option>
<option value="Illinois - IL">Illinois - IL</option>
<option value="Indiana - IN">Indiana - IN</option>
<option value="Iowa - IA">Iowa - IA</option>
<option value="Kansas - KS">Kansas - KS</option>
<option value="Kentucky - KY">Kentucky - KY</option>
<option value="Louisiana - LA">Louisiana - LA</option>
<option value="Maine - ME">Maine - ME</option>
<option value="Marshall Islands* - MH">Marshall Islands* - MH</option>
<option value="Maryland - MD">Maryland - MD</option>
<option value="Massachusetts - MA">Massachusetts - MA</option>
<option value="Michigan - MI">Michigan - MI</option>
<option value="Minnesota - MN">Minnesota - MN</option>
<option value="Mississippi - MS">Mississippi - MS</option>
<option value="Missouri - MO">Missouri - MO</option>
<option value="Montana - MT">Montana - MT</option>
<option value="Nebraska - NE">Nebraska - NE</option>
<option value="Nevada - NV">Nevada - NV</option>
<option value="New Hampshire - NH">New Hampshire - NH</option>
<option value="New Jersey - NJ">New Jersey - NJ</option>
<option value="New Mexico - NM">New Mexico - NM</option>
<option value="New York - NY">New York - NY</option>
<option value="North Carolina - NC">North Carolina - NC</option>
<option value="North Dakota - ND">North Dakota - ND</option>
<option value="Northern Mariana Islands - MP">Northern Mariana Islands - MP</option>
<option value="Ohio - OH">Ohio - OH</option>
<option value="Oklahoma - OK">Oklahoma - OK</option>
<option value="Oregon - OR">Oregon - OR</option>
<option value="Palau* - PW">Palau* - PW</option>
<option value="Pennsylvania - PA">Pennsylvania - PA</option>
<option value="Puerto Rico - PR">Puerto Rico - PR</option>
<option value="Rhode Island - RI">Rhode Island - RI</option>
<option value="South Carolina - SC">South Carolina - SC</option>
<option value="South Dakota - SD">South Dakota - SD</option>
<option value="Tennessee - TN">Tennessee - TN</option>
<option value="Texas - TX">Texas - TX</option>
<option value="Utah - UT">Utah - UT</option>
<option value="Vermont - VT">Vermont - VT</option>
<option value="Virgin Island - VI">Virgin Island - VI</option>
<option value="Virginia - VA">Virginia - VA</option>
<option value="Washington - WA">Washington - WA</option>
<option value="West Virginia - WV">West Virginia - WV</option>
<option value="Wisconsin - WI">Wisconsin - WI</option>
<option value="Wyoming - WY">Wyoming - WY</option>
</select></li>
<li><label>ZIP</label>
<input class="cf_inputbox" maxlength="150" size="10" id="text_27" name="secondary_zip" type="text" /></li>
</ol>
<h4>Phone and E-mail</h4>
<ol>
<li><label>Home Phone</label>
<input class="cf_inputbox" maxlength="150" size="30" id="text_28" name="secondary_home_phone" type="text" />
</li>
<li><label>Mobile Phone</label>
<input class="cf_inputbox" maxlength="150" size="30" id="text_29" name="secondary_mobile_phone" type="text" />
</li>
<li><label>Work Phone</label>
<input class="cf_inputbox" maxlength="150" size="30" id="text_30" name="secondary_work_phone" type="text" />
</li>
<li><label>E-mail address</label>
<input class="cf_inputbox validate-email" maxlength="150" size="29" id="text_31" name="secondary_email" type="text" />
</li></ol>
<h4>Employer Information</h4>
<ol><li>
<label>Occupation</label>
<input class="cf_inputbox" maxlength="150" size="45" id="text_32" name="secondary_occupation" type="text" />
</li>
<li><label>Employer</label>
<input class="cf_inputbox" maxlength="150" size="45" id="text_33" name="secondary_employer" type="text" />
</li>
<li><label>Business Street Address</label>
<textarea class="cf_inputbox" rows="2" id="text_34" cols="30" name="secondary_business_street"></textarea>
</li>
<li><label>Business City</label>
<input class="cf_inputbox" maxlength="150" size="30" id="text_35" name="secondary_business_city" type="text" />
</li>
<li><label>Business State</label>
<select class="cf_inputbox" id="select_8" size="1" name="secondary_business_state">
<option value="">Choose Option</option>
<option value="Alabama - AL">Alabama - AL</option>
<option value="Alaska - AK">Alaska - AK</option>
<option value="American Samoa - AS">American Samoa - AS</option>
<option value="Arizona - AZ">Arizona - AZ</option>
<option value="Arkansas - AR">Arkansas - AR</option>
<option value="California - CA">California - CA</option>
<option selected="selected" value="Colorado - CO">Colorado - CO</option>
<option value="Connecticut - CT">Connecticut - CT</option>
<option value="Delaware - DE">Delaware - DE</option>
<option value="District of Columbia - DC">District of Columbia - DC</option>
<option value="Federated States of Micronesia* - FM">Federated States of Micronesia* - FM</option>
<option value="Florida - FL">Florida - FL</option>
<option value="Georgia - GA">Georgia - GA</option>
<option value="Guam - GU">Guam - GU</option>
<option value="Hawaii - HI">Hawaii - HI</option>
<option value="Idaho - ID">Idaho - ID</option>
<option value="Illinois - IL">Illinois - IL</option>
<option value="Indiana - IN">Indiana - IN</option>
<option value="Iowa - IA">Iowa - IA</option>
<option value="Kansas - KS">Kansas - KS</option>
<option value="Kentucky - KY">Kentucky - KY</option>
<option value="Louisiana - LA">Louisiana - LA</option>
<option value="Maine - ME">Maine - ME</option>
<option value="Marshall Islands* - MH">Marshall Islands* - MH</option>
<option value="Maryland - MD">Maryland - MD</option>
<option value="Massachusetts - MA">Massachusetts - MA</option>
<option value="Michigan - MI">Michigan - MI</option>
<option value="Minnesota - MN">Minnesota - MN</option>
<option value="Mississippi - MS">Mississippi - MS</option>
<option value="Missouri - MO">Missouri - MO</option>
<option value="Montana - MT">Montana - MT</option>
<option value="Nebraska - NE">Nebraska - NE</option>
<option value="Nevada - NV">Nevada - NV</option>
<option value="New Hampshire - NH">New Hampshire - NH</option>
<option value="New Jersey - NJ">New Jersey - NJ</option>
<option value="New Mexico - NM">New Mexico - NM</option>
<option value="New York - NY">New York - NY</option>
<option value="North Carolina - NC">North Carolina - NC</option>
<option value="North Dakota - ND">North Dakota - ND</option>
<option value="Northern Mariana Islands - MP">Northern Mariana Islands - MP</option>
<option value="Ohio - OH">Ohio - OH</option>
<option value="Oklahoma - OK">Oklahoma - OK</option>
<option value="Oregon - OR">Oregon - OR</option>
<option value="Palau* - PW">Palau* - PW</option>
<option value="Pennsylvania - PA">Pennsylvania - PA</option>
<option value="Puerto Rico - PR">Puerto Rico - PR</option>
<option value="Rhode Island - RI">Rhode Island - RI</option>
<option value="South Carolina - SC">South Carolina - SC</option>
<option value="South Dakota - SD">South Dakota - SD</option>
<option value="Tennessee - TN">Tennessee - TN</option>
<option value="Texas - TX">Texas - TX</option>
<option value="Utah - UT">Utah - UT</option>
<option value="Vermont - VT">Vermont - VT</option>
<option value="Virgin Island - VI">Virgin Island - VI</option>
<option value="Virginia - VA">Virginia - VA</option>
<option value="Washington - WA">Washington - WA</option>
<option value="West Virginia - WV">West Virginia - WV</option>
<option value="Wisconsin - WI">Wisconsin - WI</option>
<option value="Wyoming - WY">Wyoming - WY</option>
</select>
</li>
<li><label>Business ZIP</label>
<input class="cf_inputbox" maxlength="150" size="10" id="text_36" name="secondary_business_zip" type="text" />
</li></ol></fieldset>
<fieldset>
<legend>Medical and Dental Information</legend>
<h3>Child's Physician</h3>
<ol><li><label>Physician Name</label>
<input class="cf_inputbox" maxlength="150" size="45" id="text_37" name="physician_name" type="text" />
</li>
<li><label>Physician Street Address</label>
<textarea class="cf_inputbox" rows="3" id="text_38" cols="30" name="physician_street"></textarea>
</li>
<li><label>Physician City</label>
<input class="cf_inputbox" maxlength="150" size="30" id="text_39" name="physician_city" type="text" />
</li>
<li><label>Physician State</label>
<select class="cf_inputbox" id="select_9" size="1" name="physician_state">
<option value="">Choose Option</option>
<option value="Alabama - AL">Alabama - AL</option>
<option value="Alaska - AK">Alaska - AK</option>
<option value="American Samoa - AS">American Samoa - AS</option>
<option value="Arizona - AZ">Arizona - AZ</option>
<option value="Arkansas - AR">Arkansas - AR</option>
<option value="California - CA">California - CA</option>
<option selected="selected" value="Colorado - CO">Colorado - CO</option>
<option value="Connecticut - CT">Connecticut - CT</option>
<option value="Delaware - DE">Delaware - DE</option>
<option value="District of Columbia - DC">District of Columbia - DC</option>
<option value="Federated States of Micronesia* - FM">Federated States of Micronesia* - FM</option>
<option value="Florida - FL">Florida - FL</option>
<option value="Georgia - GA">Georgia - GA</option>
<option value="Guam - GU">Guam - GU</option>
<option value="Hawaii - HI">Hawaii - HI</option>
<option value="Idaho - ID">Idaho - ID</option>
<option value="Illinois - IL">Illinois - IL</option>
<option value="Indiana - IN">Indiana - IN</option>
<option value="Iowa - IA">Iowa - IA</option>
<option value="Kansas - KS">Kansas - KS</option>
<option value="Kentucky - KY">Kentucky - KY</option>
<option value="Louisiana - LA">Louisiana - LA</option>
<option value="Maine - ME">Maine - ME</option>
<option value="Marshall Islands* - MH">Marshall Islands* - MH</option>
<option value="Maryland - MD">Maryland - MD</option>
<option value="Massachusetts - MA">Massachusetts - MA</option>
<option value="Michigan - MI">Michigan - MI</option>
<option value="Minnesota - MN">Minnesota - MN</option>
<option value="Mississippi - MS">Mississippi - MS</option>
<option value="Missouri - MO">Missouri - MO</option>
<option value="Montana - MT">Montana - MT</option>
<option value="Nebraska - NE">Nebraska - NE</option>
<option value="Nevada - NV">Nevada - NV</option>
<option value="New Hampshire - NH">New Hampshire - NH</option>
<option value="New Jersey - NJ">New Jersey - NJ</option>
<option value="New Mexico - NM">New Mexico - NM</option>
<option value="New York - NY">New York - NY</option>
<option value="North Carolina - NC">North Carolina - NC</option>
<option value="North Dakota - ND">North Dakota - ND</option>
<option value="Northern Mariana Islands - MP">Northern Mariana Islands - MP</option>
<option value="Ohio - OH">Ohio - OH</option>
<option value="Oklahoma - OK">Oklahoma - OK</option>
<option value="Oregon - OR">Oregon - OR</option>
<option value="Palau* - PW">Palau* - PW</option>
<option value="Pennsylvania - PA">Pennsylvania - PA</option>
<option value="Puerto Rico - PR">Puerto Rico - PR</option>
<option value="Rhode Island - RI">Rhode Island - RI</option>
<option value="South Carolina - SC">South Carolina - SC</option>
<option value="South Dakota - SD">South Dakota - SD</option>
<option value="Tennessee - TN">Tennessee - TN</option>
<option value="Texas - TX">Texas - TX</option>
<option value="Utah - UT">Utah - UT</option>
<option value="Vermont - VT">Vermont - VT</option>
<option value="Virgin Island - VI">Virgin Island - VI</option>
<option value="Virginia - VA">Virginia - VA</option>
<option value="Washington - WA">Washington - WA</option>
<option value="West Virginia - WV">West Virginia - WV</option>
<option value="Wisconsin - WI">Wisconsin - WI</option>
<option value="Wyoming - WY">Wyoming - WY</option>
</select>
</li>
<li><label>Physician ZIP</label>
<input class="cf_inputbox" maxlength="150" size="10" id="text_40" name="physician_zip" type="text" />
</li></ol>
<h3>Child's Dentist</h3>
<p><i>If you do not have a dentist for your child yet, please list your dentist’s name in case there is an
emergency. </i></p>
<ol><li><label>Dentist Name</label>
<input class="cf_inputbox" maxlength="150" size="45" id="text_41" name="Dentist_name" type="text" />
</li>
<li><label>Dentist Street Address</label>
<textarea class="cf_inputbox" rows="3" id="text_42" cols="30" name="Dentist_street"></textarea>
</li>
<li><label>Dentist City</label>
<input class="cf_inputbox" maxlength="150" size="30" id="text_43" name="Dentist_city" type="text" />
</li>
<li><label>Dentist State</label>
<select class="cf_inputbox" id="select_10" size="1" name="Dentist_state">
<option value="">Choose Option</option>
<option value="Alabama - AL">Alabama - AL</option>
<option value="Alaska - AK">Alaska - AK</option>
<option value="American Samoa - AS">American Samoa - AS</option>
<option value="Arizona - AZ">Arizona - AZ</option>
<option value="Arkansas - AR">Arkansas - AR</option>
<option value="California - CA">California - CA</option>
<option selected="selected" value="Colorado - CO">Colorado - CO</option>
<option value="Connecticut - CT">Connecticut - CT</option>
<option value="Delaware - DE">Delaware - DE</option>
<option value="District of Columbia - DC">District of Columbia - DC</option>
<option value="Federated States of Micronesia* - FM">Federated States of Micronesia* - FM</option>
<option value="Florida - FL">Florida - FL</option>
<option value="Georgia - GA">Georgia - GA</option>
<option value="Guam - GU">Guam - GU</option>
<option value="Hawaii - HI">Hawaii - HI</option>
<option value="Idaho - ID">Idaho - ID</option>
<option value="Illinois - IL">Illinois - IL</option>
<option value="Indiana - IN">Indiana - IN</option>
<option value="Iowa - IA">Iowa - IA</option>
<option value="Kansas - KS">Kansas - KS</option>
<option value="Kentucky - KY">Kentucky - KY</option>
<option value="Louisiana - LA">Louisiana - LA</option>
<option value="Maine - ME">Maine - ME</option>
<option value="Marshall Islands* - MH">Marshall Islands* - MH</option>
<option value="Maryland - MD">Maryland - MD</option>
<option value="Massachusetts - MA">Massachusetts - MA</option>
<option value="Michigan - MI">Michigan - MI</option>
<option value="Minnesota - MN">Minnesota - MN</option>
<option value="Mississippi - MS">Mississippi - MS</option>
<option value="Missouri - MO">Missouri - MO</option>
<option value="Montana - MT">Montana - MT</option>
<option value="Nebraska - NE">Nebraska - NE</option>
<option value="Nevada - NV">Nevada - NV</option>
<option value="New Hampshire - NH">New Hampshire - NH</option>
<option value="New Jersey - NJ">New Jersey - NJ</option>
<option value="New Mexico - NM">New Mexico - NM</option>
<option value="New York - NY">New York - NY</option>
<option value="North Carolina - NC">North Carolina - NC</option>
<option value="North Dakota - ND">North Dakota - ND</option>
<option value="Northern Mariana Islands - MP">Northern Mariana Islands - MP</option>
<option value="Ohio - OH">Ohio - OH</option>
<option value="Oklahoma - OK">Oklahoma - OK</option>
<option value="Oregon - OR">Oregon - OR</option>
<option value="Palau* - PW">Palau* - PW</option>
<option value="Pennsylvania - PA">Pennsylvania - PA</option>
<option value="Puerto Rico - PR">Puerto Rico - PR</option>
<option value="Rhode Island - RI">Rhode Island - RI</option>
<option value="South Carolina - SC">South Carolina - SC</option>
<option value="South Dakota - SD">South Dakota - SD</option>
<option value="Tennessee - TN">Tennessee - TN</option>
<option value="Texas - TX">Texas - TX</option>
<option value="Utah - UT">Utah - UT</option>
<option value="Vermont - VT">Vermont - VT</option>
<option value="Virgin Island - VI">Virgin Island - VI</option>
<option value="Virginia - VA">Virginia - VA</option>
<option value="Washington - WA">Washington - WA</option>
<option value="West Virginia - WV">West Virginia - WV</option>
<option value="Wisconsin - WI">Wisconsin - WI</option>
<option value="Wyoming - WY">Wyoming - WY</option>
</select>
</li>
<li><label>Dentist ZIP</label>
<input class="cf_inputbox" maxlength="150" size="10" id="text_44" name="Dentist_zip" type="text" />
</li></ol>
<h3>Hospital</h3>
<ol><li><label>Please specify your hospital of choice:</label><input class="cf_inputbox" maxlength="150" size="45" id="text_45" name="hospital" type="text" /></li></ol>
<h3>Allergies, Medical Problems, and Special Needs</h3>
<ol><li><label>Does your child have any allergies or medical problems?</label>
<input value="Yes" class="radio radio" id="allergies_or_medical_issues" name="allergies_medical" type="radio" />
<label for="allergies_or_medical_issues" class="radio_label">Yes</label>
</li>
<li><label>If Yes, please explain:</label><input class="cf_inputbox" maxlength="150" size="45" id="text_46" name="allergies_or_medical_problems" type="text" /></li>
<li><input value="No" class="radio radio" id="No" name="allergies_medical" type="radio" />
<label for="No" class="radio_label">No</label></li>
<li><label>Has your child had chicken pox or received the chicken pox vaccine (or will have by enrollment date)?</label>
<input value="Yes" class="radio radio" id="chicken_pox_or_vaccine" name="chicken_pox" type="radio" />
<label for="chicken_pox_or_vaccine" class="radio_label">Yes</label>
</li>
<li><input value="No" class="radio radio" id="No_chicken_pox_or_vaccine" name="chicken_pox" type="radio" />
<label for="No_chicken_pox_or_vaccine" class="radio_label">No</label></li>
<li><label>Please note any special needs your child has, such as food allergies, assistance using the bathroom, etc.:</label><textarea class="cf_inputbox" rows="4" id="text_47" cols="42" name="special_needs"></textarea></li></ol>
<h3>Potty Training</h3>
<p><strong>For children enrolling in the Polliwogs or Frogs class only:</strong></p>
<ol><li><label>Is your child potty trained – or will be by enrollment date? </label>
<input value="Yes" class="radio radio" id="potty_trained" name="potty_trained" type="radio" />
<label for="potty_trained" class="radio_label">Yes</label>
</li>
<li><input value="No" class="radio radio" id="Not_potty_trained" name="potty_trained" type="radio" />
<label for="Not_potty_trained" class="radio_label">No</label></li>
<li><label>Comments:</label><input class="cf_inputbox" maxlength="150" size="45" id="text_48" name="potty_training_comments" type="text" /></li>
<li><label>Are you currently working on potty training?</label>
<input value="Yes" class="radio radio" id="working_on_potty_training" name="working_on_potty_training" type="radio" />
<label for="working_on_potty_training" class="radio_label">Yes</label>
</li>
<li><input value="No" class="radio radio" id="Not_working_on_potty_training" name="working_on_potty_training" type="radio" />
<label for="Not_working_on_potty_training" class="radio_label">No</label></li>
<li><label>Comments:</label><input class="cf_inputbox" maxlength="150" size="45" id="text_49" name="potty_training_comments" type="text" /></li></ol>
</fieldset>
<fieldset>
<legend>Form Submission</legend>
<p>Please review the form prior to submission to make sure you've filled out all the information correctly. If you attempt to submit the form without required information, you will be directed to complete the form before re-submitting. You will receive an e-mail copy of the form (sent to the Primary Parent/Guardian's e-mail address) as confirmation of successful submittal. The form data will be stored in the school's database and submitted via e-mail to the enrollment coordinator.</p>
<div class="form_item">
<div class="form_element cf_captcha">
<label class="cf_label">Please copy the image text in the box to verify you're not a spambot:</label>
<span>{imageverification}</span>
</div>
<input value="Submit" type="submit" /> <input value="Reset" type="reset" />
<div class="clear">Â </div>
</div>
</fieldset>