Please fill out all of the required fields (*).
'; // format and send the email } else { $form = "clear"; // formats the text for the email $body = "

Student Information


" . "First Name: {$_POST['first']}
" . "Last Name: {$_POST['last']}
" . "Address: {$_POST['address']}
" . "City: {$_POST['city']}
" . "Postal Code: {$_POST['postal']}
" . "Date of Birth: {$_POST['birthday']}
" . "Home Phone: {$_POST['phone']}
" . "Cell Phone: {$_POST['cellPhone']}
" . "Email: {$_POST['email']}
" . "I consent to receiving electronic communications from the SCSA: {$_POST['consent']}
" . "
" . "

Employer Information


" . "Company Name: {$_POST['company']}
" . "Address: {$_POST['companyAddress']}
" . "City: {$_POST['companyCity']}
" . "Postal Code: {$_POST['workPostal']}
" . "Phone: {$_POST['workPhone']}
" . "Fax: {$_POST['workFax']}
" . "Email: {$_POST['workEmail']}
" . "Contact Name: {$_POST['contactName']}
"; $body = wordwrap($body, 110); // format the header for the mail function $headers = "From: no-reply@scsaonline.ca" . "\r\n"; $headers .= "Reply-To: " . "{$_POST['email']}" . "\r\n"; $headers .= "MIME-Version: 1.0\r\n"; $headers .= "Content-Type: text/html; charset=ISO-8859-1\r\n"; //mail function mail('scsaprograminfo@scsaonline.ca', 'SCSA Registration Form - HSA', $body, $headers); if ($_POST['consent'] == 'yes') { mail('comm@scsaonline.ca', 'SCSA Registration Form - HSA', $body, $headers); } $formResult = 'Your application was sent successfully!
'; $_SESSION['body'] = $body; header('Location: http://www.scsaonline.ca/confirmation'); } } ?> National Health and Safety Administrator (NHSA™) Program - Saskatchewan Construction Safety Association

Registration Form

Health and Safety Administrator (HSA)

1. Student Information:

First Name (*)
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Last Name (*)
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Address (*)
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City (*)
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Postal Code (*)
" />
Date of Birth (Year/Month/Day) (*)
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Home Phone (*)
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Cell Phone
" />
Email (*)
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2. Employer Information:

Company Name
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Address
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City
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Postal Code
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Phone
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Fax
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E-mail (*)
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Contact Name
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