UPMC BU > CloudPages > API Internal Testing Forms > Volunteer Referral Form - TEST FORM


      <h2>Volunteer Referral Form - Test Form</h2>
      <form action="https://pages.upmc.com/volunteer-referral-form-api-internal-testing-form" method="post">
         
         <label>Applicant Name</label>
         <input type="text" name="applicant_name"><br>

         <label>Facility Location</label>
            <select name="facility_location" id="facility_location">
                <option value="" selected="selected">Select One</option>
                <option value="Family Hospice & Palliative Care East/Healing">Family Hospice & Palliative Care East/Healing</option>
                <option value="Family Hospice & Palliative Care Northern Tier">Family Hospice & Palliative Care Northern Tier</option>
                <!--
                <option value="value_here">value_here</option>
                <option value="value_here">value_here</option>
                <option value="value_here">value_here</option>
                <option value="value_here">value_here</option>
                -->
            </select><br>
         
         <label>How long have you known this applicant?</label>
         <input type="text" name="applicant_time_known"><br>

         <label>In what capacity have you known the applicant?</label>
        <textarea type="text" name="relationship_to_applicant"></textarea><br> 

        <label>Describe the applicant’s reliability and willingness to make a commitment to volunteer:</label>
        <textarea type="text" name="applicant_reliability"></textarea><br> 

        <label>Please comment on the applicant’s attitude and other characteristics such as dependability:</label>
        <textarea type="text" name="applicant_attitude"></textarea><br> 

        <label>Would you have any reservations about recommending this candidate for volunteer services?</label><br>
            <input type="radio" id="Yes" name="reservations" value="Yes">
                <label for="Yes">Yes</label><br>
            <input type="radio" id="No" name="reservations" value="No">
                <label for="No">No</label><br>
         
         <label>Reference Name</label>
         <input type="text" name="reference_name"><br>
         <label>Reference Email</label>
         <input type="text" name="email_address"><br>
         <label>Reference Phone</label>
         <input type="text" name="reference_phone"><br>

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