<%@LANGUAGE="VBSCRIPT"%> <% ' *** Edit Operations: declare variables Dim MM_editAction Dim MM_abortEdit Dim MM_editQuery Dim MM_editCmd Dim MM_editConnection Dim MM_editTable Dim MM_editRedirectUrl Dim MM_editColumn Dim MM_recordId Dim MM_fieldsStr Dim MM_columnsStr Dim MM_fields Dim MM_columns Dim MM_typeArray Dim MM_formVal Dim MM_delim Dim MM_altVal Dim MM_emptyVal Dim MM_i MM_editAction = CStr(Request.ServerVariables("SCRIPT_NAME")) If (Request.QueryString <> "") Then MM_editAction = MM_editAction & "?" & Request.QueryString End If ' boolean to abort record edit MM_abortEdit = false ' query string to execute MM_editQuery = "" %> <% ' *** Insert Record: set variables If (CStr(Request("MM_insert")) = "frmmodadd") Then MM_editConnection = MM_oconnrmfire_STRING MM_editTable = "dbo.LifeData" MM_editRedirectUrl = "LifeDataConfirm.asp" MM_fieldsStr = "txtfname|value|txtlname|value|txtadd|value|txtcity|value|txtstate|value|txtzip|value|txtphone|value|txtemail|value|txtcounty|value|txtdob|value|txtcontact|value|txtcontactph|value|txtdoctor|value|txtdoctorph|value|txtmajmed|value|txtmedication|value|txtemerloc|value|txtmoreinfo|value|txtuserid|value|txtpass|value" MM_columnsStr = "Fname|',none,''|Lname|',none,''|PrptyAdd|',none,''|PrptyCity|',none,''|PrptyState|',none,''|PrptyZip|',none,''|Phone|',none,''|Email|',none,''|PrptyCounty|',none,''|DOB|',none,NULL|Contact|',none,''|ContactPh|',none,''|DocName|',none,''|DocPhone|',none,''|MajMedCond|',none,''|Medications|',none,''|EmerInfoLoc|',none,''|AddNotes|',none,''|Userid|',none,''|Password|',none,''" ' create the MM_fields and MM_columns arrays MM_fields = Split(MM_fieldsStr, "|") MM_columns = Split(MM_columnsStr, "|") ' set the form values For MM_i = LBound(MM_fields) To UBound(MM_fields) Step 2 MM_fields(MM_i+1) = CStr(Request.Form(MM_fields(MM_i))) Next ' append the query string to the redirect URL If (MM_editRedirectUrl <> "" And Request.QueryString <> "") Then If (InStr(1, MM_editRedirectUrl, "?", vbTextCompare) = 0 And Request.QueryString <> "") Then MM_editRedirectUrl = MM_editRedirectUrl & "?" & Request.QueryString Else MM_editRedirectUrl = MM_editRedirectUrl & "&" & Request.QueryString End If End If End If %> <% ' *** Insert Record: construct a sql insert statement and execute it Dim MM_tableValues Dim MM_dbValues If (CStr(Request("MM_insert")) <> "") Then ' create the sql insert statement MM_tableValues = "" MM_dbValues = "" For MM_i = LBound(MM_fields) To UBound(MM_fields) Step 2 MM_formVal = MM_fields(MM_i+1) MM_typeArray = Split(MM_columns(MM_i+1),",") MM_delim = MM_typeArray(0) If (MM_delim = "none") Then MM_delim = "" MM_altVal = MM_typeArray(1) If (MM_altVal = "none") Then MM_altVal = "" MM_emptyVal = MM_typeArray(2) If (MM_emptyVal = "none") Then MM_emptyVal = "" If (MM_formVal = "") Then MM_formVal = MM_emptyVal Else If (MM_altVal <> "") Then MM_formVal = MM_altVal ElseIf (MM_delim = "'") Then ' escape quotes MM_formVal = "'" & Replace(MM_formVal,"'","''") & "'" Else MM_formVal = MM_delim + MM_formVal + MM_delim End If End If If (MM_i <> LBound(MM_fields)) Then MM_tableValues = MM_tableValues & "," MM_dbValues = MM_dbValues & "," End If MM_tableValues = MM_tableValues & MM_columns(MM_i) MM_dbValues = MM_dbValues & MM_formVal Next MM_editQuery = "insert into " & MM_editTable & " (" & MM_tableValues & ") values (" & MM_dbValues & ")" If (Not MM_abortEdit) Then ' execute the insert Set MM_editCmd = Server.CreateObject("ADODB.Command") MM_editCmd.ActiveConnection = MM_editConnection MM_editCmd.CommandText = MM_editQuery MM_editCmd.Execute MM_editCmd.ActiveConnection.Close If (MM_editRedirectUrl <> "") Then Response.Redirect(MM_editRedirectUrl) End If End If End If %> LifeData Registration Form
General Information
 Indicates a required field
First Name:
Last Name:
Property Address:
City
State
 Zip Code
Phone:
 
Email:
County area:
  		 

LifeData Information

        

Date of Birth: [MM/DD/YYYY]

Contact Person:

Contact Phone:

Physician's Name:

Physician's Phone:

 

Major Medical Condition(s):


Medications:

Location of Emergency Information:

Additional information you feel would be helpful to our emergency crews:

I hereby acknowledge that I am 18 years of age or older.

*Rural/Metro Fire Department follows federal guidelines with the disclosure of private health information(PHI). To read more see our notice of privacy practices.