<span class="text"><font color="#ffffff" class="text"> <p style="text-align: center; "><img alt="" src="/users/HollandGrumieaux8023/Image//new%20logosmall%20for%20student.jpg" /></p> <p style="text-align: left"> </p> <p style="text-align: left"><span style="font-size: large"><strong><span style="font-family: Verdana">NYC Fashion Summer Camp Application</span></strong></span></p> <form method="post" action="/mailercustom.html"> <input type="hidden" value="/site19/iframe.html?page=7" name="endurl" /><input type="hidden" value="FirstName,LastName,Email Address" name="reqs" /><input type="hidden" value="Thank you for contacting us. We will get back to you shortly" name="themessage" /> <p> </p> <table width="647" height="817" border="0" align="center" cellpadding="4" cellspacing="0"> <tbody> <tr> <td>First Name <br /> <input name="FirstName" type="text" id="FirstName" /></td> <td>Last Name <br /> <input name="LastName" type="text" id="LastName" /></td> <td width="200">Gender<br /> M <input type="radio" name="Male" value="Male" /> F <input type="radio" name="Female" value="Female" /></td> </tr> <tr> <td colspan="2">Date of Birth<br /> <input name="DateOfBirth" type="text" id="DateOfBirth" /></td> <td> </td> </tr> <tr> <td colspan="2">Name of School <br /> <input name="SchoolName" type="text" id="SchoolName" size="50" /></td> <td> <p>Grade Entering (Fall 2011)</p> <p><input name="2010Grade" type="text" id="2010Grade" /></p> </td> </tr> <tr> <td>Cell Phone Number<br /> <input name="Cell Phone Number" type="text" id="Cell Phone Number" /></td> <td>Home Phone Number<br /> <input name="Home Phone Number" type="text" id="Home Phone Number" /></td> <td> </td> </tr> <tr> <td colspan="2">Email Address <br /> <input name="Email Address" type="text" id="Email Address" /></td> <td> </td> </tr> <tr> <td colspan="2"> <table border="0" cellpadding="0" cellspacing="0"> <tbody> <tr> <td>Address<br /> <input name="Address" type="text" id="Address" size="20" /></td> <td> </td> <td>City <br /> <input name="City" type="text" id="City" size="15" /></td> <td> </td> <td>State <br /> <input name="State" type="text" id="State" size="3" /></td> <td> </td> <td>Zip Code<br /> <input name="textfield" type="text" size="12" /></td> </tr> </tbody> </table> </td> <td>Country<br /> <input name="Country" type="text" id="Country" /></td> </tr> <tr> <td colspan="3">Family Information</td> </tr> <tr> <td>Mother's First Name <br /> <input name="MotherFirstName" type="text" id="MotherFirstName" /></td> <td>Mother's Last Name <input name="MotherLastName" type="text" id="MotherLastName" /></td> </tr> <tr> <td>Mother's Cell Phone Number<br /> <input name="MotherCellPhone" type="text" id="MotherCellPhone" /></td> <td>Mother's Home Phone Number<br /> <input name="MotherHomePhone" type="text" id="MotherHomePhone" /></td> <td> </td> </tr> <tr> <td colspan="2">Mother's Email Address <br /> <input name="MotherEmailAddress" type="text" id="MotherEmailAddress" size="50" /></td> <td> </td> </tr> <tr> <td colspan="2"> <table border="0" cellpadding="0" cellspacing="0"> <tbody> <tr> <td>Mother's Address<br /> <input name="Address" type="text" id="MotherAddress" size="20" /></td> <td> </td> <td>City <br /> <input name="City" type="text" id="City" size="15" /></td> <td> </td> <td>State <br /> <input name="State" type="text" id="State" size="3" /></td> <td> </td> <td>Zip Code<br /> <input name="textfield" type="text" size="12" /></td> </tr> </tbody> </table> </td> <td>Country<br /> <input name="Country" type="text" id="Country" /></td> </tr> <tr> <td>Father's First Name <br /> <input name="FatherFirstName" type="text" id="FatherFirstName" /></td> <td>Father's Last Name <input name="FatherLastName" type="text" id="FatherLastName" /></td> </tr> <tr> <td>Father's Cell Phone Number<br /> <input name="FatherCellPhone" type="text" id="FatherCellPhone" /></td> <td>Father's Home Phone Number<br /> <input name="FatherHomePhone" type="text" id="FatherHomePhone" /></td> <td> </td> </tr> <tr> <td colspan="2">Father's Email Address <br /> <input name="FatherEmailAddress" type="text" id="FatherEmailAddress" size="50" /></td> <td> </td> </tr> <tr> <td colspan="2"> <table border="0" cellpadding="0" cellspacing="0"> <tbody> <tr> <td>Father's Address<br /> <input name="Address" type="text" id="FatherAddress" size="20" /></td> <td> </td> <td>City <br /> <input name="City" type="text" id="City" size="15" /></td> <td> </td> <td>State <br /> <input name="State" type="text" id="State" size="3" /></td> <td> </td> <td>Zip Code<br /> <input name="textfield" type="text" size="12" /></td> </tr> </tbody> </table> </td> <td>Country<br /> <input name="Country" type="text" id="Country" /></td> </tr> <tr> <td>Parent/Student Questions</td> </tr> <tr> <td colspan="3">Why do you want to attend a Banson NYC Fashion Summer Camp?<br /> <textarea name="WhydoYouWantToAttend" cols="75" id="WhydoYouWantToAttend"></textarea></td> </tr> <tr> <td colspan="3">How did you hear about Banson NYC?<br /> <input name="HowDidYouHearOfUs" type="text" id="HowDidYouHearOfUs" /></td> </tr> <tr> <td colspan="2"> <p>Which session would you like to attend?</p> <p>Session A: June 26, 2011 – July 2, 2011 <input type="radio" name="June28" value="radiobutton" /> <br /> Session B: July 17, 2011 – July 23, 2011 <input type="radio" name="July19" value="radiobutton" /> <br /> </p> </td> </tr> <tr> <td width="200">Are you registering with a friend?<br /> Y <input type="radio" name="FriendYes" value="Yes" /> N <input type="radio" name="FriendNo" value="No" /></td> </tr> <tr> <td>If yes, what is your friends name?<br /> <input name="FriendsName" type="text" id="FriendsName" /></td> </tr> <tr> <td colspan="3" align="center"><em>We can't wait to hear from you!</em><br /> <br /> <input type="submit" name="submit" value="Submit" /></td> </tr> </tbody> </table> </form></font></span><br> <h1> </h1>
