School Form Requests

<p> <p> &lt;h1&gt;School Form Requests&lt;/h1&gt; &lt;form method=&quot;post&quot; name=&quot;contactForm&quot; action=&quot;assets/php/tntforms.php&quot;&gt; &lt;input type=&quot;hidden&quot; value=&quot;../../thank-you.html&quot; name=&quot;redirect&quot; /&gt; &lt;input type=&quot;hidden&quot; name=&quot;env_report&quot; value=&quot;REMOTE_HOST,HTTP_USER_AGENT&quot; /&gt; &lt;div style=&quot;margin-bottom: 3px;&quot;&gt;Your Name:&lt;/div&gt; &lt;input type=&quot;text&quot; style=&quot;margin-bottom: 5px;&quot; name=&quot;parent name&quot; value=&quot;&quot; /&gt; &lt;div style=&quot;margin-bottom: 3px;&quot;&gt;Your Child&#39;s Name:&lt;/div&gt; &lt;input type=&quot;text&quot; style=&quot;margin-bottom: 5px;&quot; name=&quot;child name&quot; value=&quot;&quot; /&gt; &lt;div style=&quot;margin-bottom: 3px;&quot;&gt;Would you like me to email or fax the form back to you?&lt;/div&gt; Email:&lt;input type=&quot;radio&quot; value=&quot;email form&quot; name=&quot;how to send&quot; /&gt; Fax: &lt;input type=&quot;radio&quot; value=&quot;fax form&quot; name=&quot;how to send&quot; /&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt; &lt;div style=&quot;margin-bottom: 3px;&quot;&gt;Your Email/Fax:&lt;/div&gt; &lt;input type=&quot;text&quot; style=&quot;margin-bottom: 5px;&quot; name=&quot;email/fax&quot; value=&quot;&quot; /&gt; &lt;div style=&quot;margin-bottom: 3px;&quot;&gt;Please Verify Code:&lt;/div&gt; &lt;img alt="" src=&quot;assets/php/CaptchaSecurityImages.php?width=100&amp;amp;height=40&amp;amp;characters=5&quot; /&gt;&lt;br /&gt; &lt;input type=&quot;text&quot; id=&quot;security_code&quot; name=&quot;security_code&quot; value=&quot;type image above&quot; onclick=&quot;if(this.value==&#39;type image above&#39;){this.value=&#39;;}&quot; /&gt; &lt;br /&gt; &lt;input type=&quot;submit&quot; value=&quot;Submit&quot; /&gt; &lt;input type=&quot;hidden&quot; value=&quot;child form requests&quot; name=&quot;subject&quot; /&gt; &lt;/form&gt; &lt;p&gt;Requests will be fulfilled within 48 hours. In order to qualify, exams must be current and have been completed within the last 6 months.&lt;a href=&quot;assets/docs/IL-School-Dental-Exam-requirements.pdf&quot; target=&quot;_blank&quot;&gt;&lt;br /&gt; &lt;/a&gt;&lt;/p&gt;</p></p>