<% recaptcha_challenge_field = Request("recaptcha_challenge_field") recaptcha_response_field = Request("recaptcha_response_field") recaptcha_public_key = "6LeGcbwSAAAAAJUgFCD9KejrRVQC66lFyPppMD7T" ' your public key recaptcha_private_key = "6LeGcbwSAAAAAB8jQkMMaoRtgs8qRk0pTMVGSwzY" ' your private key ' returns the HTML for the widget function recaptcha_challenge_writer() recaptcha_challenge_writer = "" & _ "" & _ "" end function ' returns "" if correct, otherwise it returns the error response function recaptcha_confirm(rechallenge,reresponse) Dim VarString VarString = _ "privatekey=" & recaptcha_private_key & _ "&remoteip=" & Request.ServerVariables("REMOTE_ADDR") & _ "&challenge=" & rechallenge & _ "&response=" & reresponse Dim objXmlHttp Set objXmlHttp = Server.CreateObject("Msxml2.ServerXMLHTTP") objXmlHttp.open "POST", "http://www.google.com/recaptcha/api/verify", False objXmlHttp.setRequestHeader "Content-Type", "application/x-www-form-urlencoded" objXmlHttp.send VarString Dim ResponseString ResponseString = split(objXmlHttp.responseText, vblf) Set objXmlHttp = Nothing if ResponseString(0) = "true" then 'They answered correctly recaptcha_confirm = "" else 'They answered incorrectly recaptcha_confirm = ResponseString(1) end if end function server_response = "" newCaptcha = True if (recaptcha_challenge_field <> "" or recaptcha_response_field <> "") then server_response = recaptcha_confirm(recaptcha_challenge_field, recaptcha_response_field) newCaptcha = False end if %> LMU-DeBusk College of Osteopathic Medicine - PA Open House Registration Form
Academics

Lincoln Memorial University-
DeBusk College of Osteopathic Medicine

Physician Assistant Program Information Session
Registration Form

Saturday, March 16, 2013, 10:30 a.m. - 12:30 p.m.
4th Floor, LMU-DCOM Building

<% if server_response <> "" or newCaptcha then %> <% if newCaptcha = False then %> <% response.write("

Captcha response invalid. Please resubmit the form.

") %> <% end if %>
">

Name

Address

City    State       Zip

Phone

Email

Name of other person attending

Name of other person attending

(If you are registering for more than one person, please include their names above.)

Are you a prospective Physician Assistant Student? Yes  No

<%=recaptcha_challenge_writer()%>

<% else %> <% 'Using CDOsys with Basic authentication in Classic ASP 'Original Author: Unknown 'Heavily Modified by: Joshua Cantrell 'Last Revision Date: 07-30-2009 'If authentication is enabled, it requires access to a mailbox on your account. 'reports 'mailFailed' - true or false 'and 'strErr' - Mail server error response 'and 'strErrCode' - Mail server numerical error response (as string) 'currently disabled 'dimension all variables (essential if 'option expicit' used) dim strHost, strErr, mailFailed dim strBody, strName, strMail dim strSubject, strFrom, strTo, strCC, strBCC, strReplyTo dim strAutoMailbox, strEmPass, ix dim fieldName, fieldValue, intFields Dim strLeft, strRedir, strRedirect Dim strNoprint 'modify for yourDomain ********************************************* 'your mail server strHost = "10.10.1.11" 'address of your outgoing mailbox 'this will appear in the headers as the originating mailbox 'strAutoMailbox = "formmail@ourarea.com" 'password for your AutoMailbox 'strEmPass = "1234" 'the name and email that appears in the "From:" line (can be different to above) 'strFrom = strName & "<" & strMail & ">" 'where to send the mail 'strTo = "janette.martin@lmunet.edu" strTo = Request.Form("zz_form_to") strTo = strTo & "@lmunet.edu" 'set the redirect variable strRedir = Request.Form("zz_redirect_to") if strRedir = "dcom" Then strRedirect = "http://www.lmunet.edu/dcom/thanks.shtml" elseif strRedir = "lmu" Then strRedirect = "http://www.lmunet.edu/thanks.shtml" end if 'where to send copies (optional) strCC = "" strBCC = "" '********************************************************************** 'collect details from the form *************************** strName = Request.Form("Name") strMail = Request.Form("Email") if strMail = "" Then strMail = "webmaster@lmunet.edu" end if 'create the "Reply To:" i.e. the name and email of the form user strFrom = strName & "<" & strMail & ">" strReplyTo = strName & "<" & strMail & ">" 'create subject string strSubject = Request.Form("zz_form_subject") 'create Body string strBody = strBody & "***************************************************" & vbCrLf 'This method will result in an unsorted form 'I left it here for reference only 'To enable it, add x to the variable list above 'and uncomment. 'For Each x In Request.Form 'strBody = strBody & x & ": " & Request.Form(x) & vbcrLf 'Next 'This method induces a count to sort the form based on 'the order of the form elements in the HTML strLeft = Left(fieldName,2) strLeft = lcase(strLeft) For ix = 1 to Request.Form.Count fieldName = Request.Form.Key(ix) fieldValue = Request.Form.Item(ix) strLeft = Left(fieldName,2) strLeft = lcase(strLeft) if strLeft <> "zz" then if lcase(fieldValue) <> "submit" then strBody = strBody & fieldName & ": " & fieldValue & vbcrLf end if end if Next 'Adds the referring page and the IP details of sender to the mail body (optional) strBody = strBody & "Requested from " & Request.ServerVariables("http_referer") & vbCrLf strBody = strBody & "Requested by " & Request.ServerVariables("REMOTE_ADDR") _ & " at " & Request.ServerVariables("REMOTE_HOST") _ & ". Server time: " & time & " " & Date & " " & vbcrlf 'note the '_' continuation character, if spreading code to the next line for readability 'send the mail ************************************************** ******* 'initialise the error response string strErr = "" 'Const cdoBasic = 1 'Use basic (clear-text) authentication. Const cdoSendUsingPort = 2 Dim iMsg Dim iConf Dim Flds Dim sMsg On Error Resume Next set iMsg = CreateObject("CDO.Message") set iConf = CreateObject("CDO.Configuration") Set Flds = iConf.Fields With Flds '.Item("http://schemas.microsoft.com/cdo/configuration/smtpauthenticate") = cdoBasic '.Item("http://schemas.microsoft.com/cdo/configuration/sendusername") = strAutoMailbox '.Item("http://schemas.microsoft.com/cdo/configuration/sendpassword") = strEmPass .Item("http://schemas.microsoft.com/cdo/configuration/sendusing") = cdoSendUsingPort .Item("http://schemas.microsoft.com/cdo/configuration/smtpserver") = strHost .Item("http://schemas.microsoft.com/cdo/configuration/smtpconnectiontimeout") = 100 .Update End With With iMsg Set .Configuration = iConf .To = strTo 'To .From = strFrom 'From: if strReplyTo <> "" then .ReplyTo = strReplyTo 'add ReplyTo: if exists end if if strCC <> "" then .CC = strCC 'add CC if exists end if if strBCC <> "" then .BCC = strBCC 'add BCC if exists end if .Subject = strSubject 'add the subject .TextBody = strBody 'add the body (this is plain text) .Send 'send the mail strErr = Err.description 'response (empty if no problems) 'note: Err.number was not available when tested live End With 'clean up Set iMsg = Nothing Set iConf = Nothing Set Flds = Nothing 'prepare report flag and string if strErr = "" then mailFailed = false strErr = "Your mail has been sent." else mailFailed = true end if %> <% 'report result 'response.write (strErr) Response.Redirect strRedirect %> <%end if%>