africa:_template

Profession: %%form_data{profession}%%
Gender: %%form_data{gender}%%
iPath Member: %%form_data{iPathmember}%%
email address: %%form_raw{email}%%
Institution: %%form_data{institution}%%
Address: %%form_data{address}%%
City: %%form_data{city}%%
Country: %%form_data{country}%%
Postal/Zip Code: %%form_data{postcode}%%
e-mail: %%form_raw{e-mail address}%%
Telephone Number: %%form_data{tel}%%
Date of Arrival: %%form_data{DofA}%%
Date of Departure: %%form_data{DofD}%%

====

[[form]]
fields:
profession:
    label: Profession
    type: select
    values:
    0: General Physician
    1: General Surgeon
    2: Surgical Oncologist
    3: Medical Oncologist
    4: Radiation Oncologist
    5: Pediatric Oncologist
    6: Oncology Nurse
    7: Research
    8: Pathologist
    9: Haematologist
    10: Epidemiologist
    11: Other
    12: Choose
    default: 12
gender:
    label: Gender
    type: select
    values:
      0: "M"
      1: "F"
    default: 0
institution:
    label: Institution
    type: text
address:
    label: Street
    type: text
city:
    label: City
    type: text
country:
    label: Country
    type: text
i-Pathmember:
    label: iPath Member
    type: select
    values:
      0: "Yes"
      1: "No"
    default: 0
postcode:
    label: Postal/Zip Code
    type: text
email:
    label: email address
    match: /^[_a-zA-Z0-9\-\+]+(\.[_a-zA-Z0-9-]+)*@[a-zA-Z0-9-]+\.[a-zA-Z0-9-]+)+$/
tel:
    label: Telephone Number
    type: text (include country and city codes) 
DofA:
    label: Date of Arrival
    type: text (DD/MM/YYYY)
DofD:
    label: Date of Departure
    type: text (DD/MM/YYYY)
[[/form]]

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