UPMC BU > CloudPages > API Internal Testing Forms > PreHospital Class Registration Form - TEST FORM


      <h2>PreHospital Class Registration Form - Test Form</h2>
      <form action="https://pages.upmc.com/pre-hospital-class-registration-form-api-internal-testing-form" method="post">
         
         <label>First Name</label>
         <input type="text" name="first_name"><br>
         <label>Last Name</label>
         <input type="text" name="last_name"><br>

         <label>Email</label>
         <input type="text" name="email_address"><br>

         <label for="birthdate">Date of Birth</label>
         <input type="date" id="birthdate" name="date_of_birth"
            value="mm-dd-yyyy"
            min="1910-01-01" max="2050-12-31"><br><br>

         <label>Primary Phone Number</label>
         <input type="text" name="phone_number"><br>

         <label>Mobile Number</label>
         <input type="text" name="mobile_number"><br>

         <label>Street Address 1</label>
         <input type="text" name="street_address_1"><br>
         <label>Street Address 2</label>
         <input type="text" name="street_address_2"><br>
         <label>City</label>
         <input type="text" name="city"><br>
         <label>County</label>
         <input type="text" name="county"><br>
         <label>State</label>
         <input type="text" name="state"><br>
         <label>Zip Code</label>
         <input type="text" name="zip_code"><br><br>

         <label>Provider Certification Number</label>
         <input type="text" name="provider_certification_number"><br><br>

         <label>Your Certification Level (Check all that apply)</label><br>
            <select name="certification_level" id="certification_level" multiple>
               <option value="EMR">EMR</option>
               <option value="EMT">EMT</option>
               <option value="AEMT">AEMT</option>
               <option value="Paramedic">Paramedic</option>
               <option value="PHRN">PHRN</option>
               <option value="PHP/PHPE">PHP/PHPE</option>
               <option value="Other">Other</option>
            </select><br><br>

         <label>Are you under UPMC or CMC Medical Command Authorization?</label><br>
         <input type="radio" id="Yes" name="medical_command_authorization" value="Yes">
            <label for="Yes">Yes</label><br>
         <input type="radio" id="No" name="medical_command_authorization" value="No">
            <label for="No">No</label><br><br>

         <label>For what EMS service do you provide care?</label>
         <input type="text" name="ems_service"><br><br>

          <label>Class Title</label>
            <select name="class_title" id="class_title">
               <option value="" selected="selected">Select One</option>
               <option value="12 Lead EKG">12 Lead EKG</option>
               <option value="ACLS">ACLS</option>
               <option value="ALS Protocall Rollout">ALS Protocall Rollout</option>
               <option value="CPAP Training">CPAP Training</option>
               <option value="Grand Rounds">Grand Rounds</option>
               <option value="ITLS">ITLS</option>
               <option value="PALS">PALS</option>
               <option value="Skills Validation">Skills Validation</option>
               <option value="Special Topic/Continuing Education">Special Topic/Continuing Education</option>
               <option value="Other">Other</option>
            </select><br><br>

         <label for="classdate">Date of Class</label>
         <input type="date" id="classdate" name="date_of_class"
            value="mm-dd-yyyy"
            min="2021-01-01" max="2050-12-31"><br><br>  

         <label>Indicate the timeslot of the class you would like to attend (if applicable)</label>
         <input type="text" name="class_timeslot"><br> <br>

         <label>Category</label>
         <input type="text" name="category"><br>
         <label>Subcategory</label>
         <input type="text" name="subcategory"><br><br>
         <input name="submitted" type="hidden" value="true" />
         <input type="submit" value="Submit">
      </form>