<table width="100%" border="0" cellspacing="0" cellpadding="0" bgcolor="#FFFFFF"> <tr> <td><span class=default> <!-- startprint --> <span class=default>Please fill out the form below.</span><span class=default><br><br> <table border=0 cellpadding=0 cellspacing=0> <tr> <form method="post" action="http://www.prize4life.org/page/volunteer_form" name="regForm" onSubmit="return checkForm()"> <td> <table border=0 cellpadding=0 cellspacing=0> <tr><td valign=top><div align=right><span class="formslabel">First Name: * </span></div></td><!--<td> </td>--><td><input type="text" name="text_1500" value="" size="30" maxlength="40" class="defaultdata"><span class="formssidetext"> </span></td></tr><tr><td valign=top><div align=right><span class="formslabel">Last Name: * </span></div></td><!--<td> </td>--><td><input type="text" name="text_1501" value="" size="30" maxlength="40" class="defaultdata"><span class="formssidetext"> </span></td></tr><tr><td valign=top><div align=right><span class="formslabel">E-mail address: * </span></div></td><!--<td> </td>--><td><input type="text" name="text_1502" value="" size="30" maxlength="40" class="defaultdata"><span class="formssidetext"> </span></td></tr><tr><td valign=top><div align=right><span class="formslabel">Subscribe to our mailing list: </span></div></td><!--<td> </td>--><td><input type="checkbox" name="checkbox_1503" value="checked" ><span class="formssidetext"> (check if 'yes')</span></td></tr><tr><td valign=top><div align=right><span class="formslabel">Country: * </span></div></td><!--<td> </td>--><td><input type="text" name="text_1504" value="" size="30" maxlength="40" class="defaultdata"><span class="formssidetext"> </span></td></tr><tr><td valign=top><div align=right><span class="formslabel">Phone Number: </span></div></td><!--<td> </td>--><td><input type="text" name="text_1505" value="" size="30" maxlength="40" class="defaultdata"><span class="formssidetext"> </span></td></tr><tr><td valign=top><div align=right><span class="formslabel">Yes, I am a person with ALS (PALS): </span></div></td><!--<td> </td>--><td><input type="checkbox" name="checkbox_1506" value="checked" ><span class="formssidetext"> (check if 'yes')</span></td></tr><tr><td valign=top><div align=right><span class="formslabel">I would like to help in the following ways.: </span></div></td><!--<td> </td>--><td><table border=0><tr><td><input type="checkbox" name="checkbox_1507_1" value="checked" ></td><td class="defaultdata">Write letters to the Editor about Prize4Life</td></tr><tr><td><input type="checkbox" name="checkbox_1507_2" value="checked" ></td><td class="defaultdata">Write a blog article about Prize4Life</td></tr><tr><td><input type="checkbox" name="checkbox_1507_3" value="checked" ></td><td class="defaultdata">Put a link to www.Prize4Life.org on my website</td></tr><tr><td><input type="checkbox" name="checkbox_1507_4" value="checked" ></td><td class="defaultdata">Contribute Now to Prize4Life</td></tr><tr><td><input type="checkbox" name="checkbox_1507_5" value="checked" ></td><td class="defaultdata">Fundraise for Prize4Life</td></tr></table><span class="formssidetext"> </span></td></tr><tr><td valign=top><div align=right><span class="formslabel">How much would you like to raise?: </span></div></td><!--<td> </td>--><td><input type="text" name="text_1526" value="" size="30" maxlength="40" class="defaultdata"><span class="formssidetext"> </span></td></tr> <tr><td colspan=2> </td></tr> <tr> <td> </td> <td><span class=formsrequiredlabel>* indicates required information<br><br></span> <input type=hidden name=emailform_action value=submitted> <input type="hidden" name="formrendertime" value="1280606272"> <input type="hidden" name="formminimumdelay" value="10"> <input type="image" name="formsubmitbutton" src="graphics_custom/modules/forms/forms_submit.gif" align="absmiddle" border="0"> <a href="http://www.prize4life.org/page/volunteer_form"><img src="graphics_custom/modules/forms/forms_clear.gif" align="absmiddle" border="0"></a> </td> </tr> </table> </td> </form> </tr> </table> <!-- stopprint --> </span></td> </tr> </table>
