Wisconsin Accessible Media Productions (WAMP) BOOK REQUEST FORM


Student First Name: Student Last Name:

School District:

Date Submitted: "> Date Needed:


Send Books To:

Address:

E-mail: Phone:


For Information, Contact:

Address:

E-mail: Phone:


Send Cost Estimate To:

Address:

E-mail: Phone:


Summer contact:

Address:

E-mail: Phone:


Book 1


TITLE:

GRADE LEVEL:

AUTHOR:

PUBLISHER:

COPYRIGHT DATE: ISBN #:

READING MODE:


Book 2


TITLE:

GRADE LEVEL:

AUTHOR:

PUBLISHER:

COPYRIGHT DATE: ISBN #:

READING MODE:


Book 3


TITLE:

GRADE LEVEL:

AUTHOR:

PUBLISHER:

COPYRIGHT DATE: ISBN #:

READING MODE:


Book 4


TITLE:

GRADE LEVEL:

AUTHOR:

PUBLISHER:

COPYRIGHT DATE: ISBN #:

READING MODE:


Book 5


TITLE:

GRADE LEVEL:

AUTHOR:

PUBLISHER:

COPYRIGHT DATE: ISBN #:

READING MODE:


Book 6


TITLE:

GRADE LEVEL:

AUTHOR:

PUBLISHER:

COPYRIGHT DATE: ISBN #:

READING MODE:


Book 7


TITLE:

GRADE LEVEL:

AUTHOR:

PUBLISHER:

COPYRIGHT DATE: ISBN #:

READING MODE:


Form Submitted By:

E-Mail address of person submitting this form:


IP Submitted From:

Please use your browsers back button and fill in the E-Maill address for the person submitting this form."; exit(); } if ($_POST['security'] != $_POST['go']){ echo "You did not answer the security question correctly.
Please use your browsers back button and fill in the correct answer."; exit(); } $to = "stacy.grandt@wcbvi.k12.wi.us, jeremiah.beasley@wcbvi.k12.wi.us, wamp@wcbvi.k12.wi.us, " . $_POST['submittedbyemail']; $headers = "From: " . $_POST['submittedbyemail']; $subject = "BOOK REQUEST FORM [From WAMP Web Site]"; $body = "Wisconsin Accessible Media Productions (WAMP)\n BOOK REQUEST FORM\n\n ---------------------------------------------\n\n Student Last Name: " . $_POST['studentlastname'] . "\n Student First Name: " . $_POST['studentfirstname'] . "\n School District: " . $_POST['district'] . "\n Date Submitted: " . $_POST['submitteddate'] . "\n Date Needed: " . $_POST['needdate'] . "\n ---------------------------------------------\n\n Send Books To: " . $_POST['sentto'] . "\n Address: " . $_POST['sendaddress'] . "\n E-mail: " . $_POST['sendemail'] . "\n Phone: " . $_POST['sendphone'] . "\n ---------------------------------------------\n\n For Information, Contact: " . $_POST['infoto'] . "\n Address: " . $_POST['infoaddress'] . "\n E-mail: " . $_POST['infoemail'] . "\n Phone: " . $_POST['infophone'] . "\n ---------------------------------------------\n\n Send Cost Estimate To: " . $_POST['costto'] . "\n Address: " . $_POST['costaddress'] . "\n E-mail: " . $_POST['costemail'] . "\n Phone: " . $_POST['costphone'] . "\n ---------------------------------------------\n\n Summer contact: " . $_POST['summerto'] . "\n Address: " . $_POST['summeraddress'] . "\n E-mail: " . $_POST['summeremail'] . "\n Phone: " . $_POST['summerphone'] . "\n ---------------------------------------------\n\n Book 1\n TITLE: " . $_POST['booktitle1'] . "\n GRADE LEVEL: " . $_POST['gradelevel1'] . "\n AUTHOR: " . $_POST['bookauthor1'] . "\n PUBLISHER: " . $_POST['bookpublisher1'] . "\n COPYRIGHT DATE: " . $_POST['bookcopyright1'] . "\n ISBN #: " . $_POST['bookisbn1'] . "\n READING MODE: " . $_POST['bookmode1'] . "\n ---------------------------------------------\n\n Book 2\n TITLE: " . $_POST['booktitle2'] . "\n GRADE LEVEL: " . $_POST['gradelevel2'] . "\n AUTHOR: " . $_POST['bookauthor2'] . "\n PUBLISHER: " . $_POST['bookpublisher2'] . "\n COPYRIGHT DATE: " . $_POST['bookcopyright2'] . "\n ISBN #: " . $_POST['bookisbn2'] . "\n READING MODE: " . $_POST['bookmode2'] . "\n ---------------------------------------------\n\n Book 3\n TITLE: " . $_POST['booktitle3'] . "\n GRADE LEVEL: " . $_POST['gradelevel3'] . "\n AUTHOR: " . $_POST['bookauthor3'] . "\n PUBLISHER: " . $_POST['bookpublisher3'] . "\n COPYRIGHT DATE: " . $_POST['bookcopyright3'] . "\n ISBN #: " . $_POST['bookisbn3'] . "\n READING MODE: " . $_POST['bookmode3'] . "\n ---------------------------------------------\n\n Book 4\n TITLE: " . $_POST['booktitle4'] . "\n GRADE LEVEL: " . $_POST['gradelevel4'] . "\n AUTHOR: " . $_POST['bookauthor4'] . "\n PUBLISHER: " . $_POST['bookpublisher4'] . "\n COPYRIGHT DATE: " . $_POST['bookcopyright4'] . "\n ISBN #: " . $_POST['bookisbn4'] . "\n READING MODE: " . $_POST['bookmode4'] . "\n ---------------------------------------------\n\n Book 5\n TITLE: " . $_POST['booktitle5'] . "\n GRADE LEVEL: " . $_POST['gradelevel5'] . "\n AUTHOR: " . $_POST['bookauthor5'] . "\n PUBLISHER: " . $_POST['bookpublisher5'] . "\n COPYRIGHT DATE: " . $_POST['bookcopyright5'] . "\n ISBN #: " . $_POST['bookisbn5'] . "\n READING MODE: " . $_POST['bookmode5'] . "\n ---------------------------------------------\n\n Book 6\n TITLE: " . $_POST['booktitle6'] . "\n GRADE LEVEL: " . $_POST['gradelevel6'] . "\n AUTHOR: " . $_POST['bookauthor6'] . "\n PUBLISHER: " . $_POST['bookpublisher6'] . "\n COPYRIGHT DATE: " . $_POST['bookcopyright6'] . "\n ISBN #: " . $_POST['bookisbn6'] . "\n READING MODE: " . $_POST['bookmode6'] . "\n ---------------------------------------------\n\n Book 7\n TITLE: " . $_POST['booktitle7'] . "\n GRADE LEVEL: " . $_POST['gradelevel7'] . "\n AUTHOR: " . $_POST['bookauthor7'] . "\n PUBLISHER: " . $_POST['bookpublisher7'] . "\n COPYRIGHT DATE: " . $_POST['bookcopyright7'] . "\n ISBN #: " . $_POST['bookisbn7'] . "\n READING MODE: " . $_POST['bookmode7'] . "\n ---------------------------------------------\n\n Form Submitted By: " . $_POST['submittedbyname'] . "\n E-Mail address of person submitting\n this form: " . $_POST['submittedbyemail'] . "\n IP Submitted From: " . $_POST['submittedip'] . "\n ---------------------------------------------\n ---------------------------------------------\n"; $bodyhtml = "
Wisconsin Accessible Media Productions (WAMP)
BOOK REQUEST FORM


---------------------------------------------

Student Last Name: " . $_POST['studentlastname'] . "
Student First Name: " . $_POST['studentfirstname'] . "
School District: " . $_POST['district'] . "
Date Submitted: " . $_POST['submitteddate'] . "
Date Needed: " . $_POST['needdate'] . "
---------------------------------------------

Send Books To: " . $_POST['sentto'] . "
Address: " . $_POST['sendaddress'] . "
E-mail: " . $_POST['sendemail'] . "
Phone: " . $_POST['sendphone'] . "
---------------------------------------------

For Information, Contact: " . $_POST['infoto'] . "
Address: " . $_POST['infoaddress'] . "
E-mail: " . $_POST['infoemail'] . "
Phone: " . $_POST['infophone'] . "
---------------------------------------------

Send Cost Estimate To: " . $_POST['costto'] . "
Address: " . $_POST['costaddress'] . "
E-mail: " . $_POST['costemail'] . "
Phone: " . $_POST['costphone'] . "
---------------------------------------------

Summer contact: " . $_POST['summerto'] . "
Address: " . $_POST['summeraddress'] . "
E-mail: " . $_POST['summeremail'] . "
Phone: " . $_POST['summerphone'] . "
---------------------------------------------

Book 1
TITLE: " . $_POST['booktitle1'] . "
GRADE LEVEL: " . $_POST['gradelevel1'] . "
AUTHOR: " . $_POST['bookauthor1'] . "
PUBLISHER: " . $_POST['bookpublisher1'] . "
COPYRIGHT DATE: " . $_POST['bookcopyright1'] . "
ISBN #: " . $_POST['bookisbn1'] . "
READING MODE: " . $_POST['bookmode1'] . "
---------------------------------------------

Book 2
TITLE: " . $_POST['booktitle2'] . "
GRADE LEVEL: " . $_POST['gradelevel2'] . "
AUTHOR: " . $_POST['bookauthor2'] . "
PUBLISHER: " . $_POST['bookpublisher2'] . "
COPYRIGHT DATE: " . $_POST['bookcopyright2'] . "
ISBN #: " . $_POST['bookisbn2'] . "
READING MODE: " . $_POST['bookmode2'] . "
---------------------------------------------

Book 3
TITLE: " . $_POST['booktitle3'] . "
GRADE LEVEL: " . $_POST['gradelevel3'] . "
AUTHOR: " . $_POST['bookauthor3'] . "
PUBLISHER: " . $_POST['bookpublisher3'] . "
COPYRIGHT DATE: " . $_POST['bookcopyright3'] . "
ISBN #: " . $_POST['bookisbn3'] . "
READING MODE: " . $_POST['bookmode3'] . "
---------------------------------------------

Book 4
TITLE: " . $_POST['booktitle4'] . "
GRADE LEVEL: " . $_POST['gradelevel4'] . "
AUTHOR: " . $_POST['bookauthor4'] . "
PUBLISHER: " . $_POST['bookpublisher4'] . "
COPYRIGHT DATE: " . $_POST['bookcopyright4'] . "
ISBN #: " . $_POST['bookisbn4'] . "
READING MODE: " . $_POST['bookmode4'] . "
---------------------------------------------

Book 5
TITLE: " . $_POST['booktitle5'] . "
GRADE LEVEL: " . $_POST['gradelevel5'] . "
AUTHOR: " . $_POST['bookauthor5'] . "
PUBLISHER: " . $_POST['bookpublisher5'] . "
COPYRIGHT DATE: " . $_POST['bookcopyright5'] . "
ISBN #: " . $_POST['bookisbn5'] . "
READING MODE: " . $_POST['bookmode5'] . "
---------------------------------------------

Book 6
TITLE: " . $_POST['booktitle6'] . "
GRADE LEVEL: " . $_POST['gradelevel6'] . "
AUTHOR: " . $_POST['bookauthor6'] . "
PUBLISHER: " . $_POST['bookpublisher6'] . "
COPYRIGHT DATE: " . $_POST['bookcopyright6'] . "
ISBN #: " . $_POST['bookisbn6'] . "
READING MODE: " . $_POST['bookmode6'] . "
---------------------------------------------

Book 7
TITLE: " . $_POST['booktitle7'] . "
GRADE LEVEL: " . $_POST['gradelevel7'] . "
AUTHOR: " . $_POST['bookauthor7'] . "
PUBLISHER: " . $_POST['bookpublisher7'] . "
COPYRIGHT DATE: " . $_POST['bookcopyright7'] . "
ISBN #: " . $_POST['bookisbn7'] . "
READING MODE: " . $_POST['bookmode7'] . "
---------------------------------------------

Form Submitted By: " . $_POST['submittedbyname'] . "
E-Mail address of person submitting
this form: " . $_POST['submittedbyemail'] . "
IP Submitted From: " . $_POST['submittedip'] . "
---------------------------------------------
---------------------------------------------
"; if (mail($to, $subject, $body, $headers)) { echo("

Form successfully sent!

"); echo($bodyhtml); } else { echo("

Message delivery failed...
Please Try again!

"); } ?>

Bookmark and Share