

     <!-- SiteMaker 6.5 CMS (TM)
     Code created by Medseek, Inc. 2028 Village Lane, Solvang CA 93463.
     Phone 1-888 MEDSEEK. email info@medseek.com. http://www.medseek.com 
     (c) 1999-2006 Medseek, Inc. All rights reserved.-->
    

	<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 3.2 Final//EN">
	<HTML>


	<HEAD>
<meta name="verify-v1" content="ZuJnvh/kKNl9sqdKUSj0tSAUXAMbDWw0zOHAnfrRhCc=" />
	<TITLE>Immunization Clinic Request Form</TITLE>
	<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1">
	<meta name="description" content="">
	<meta name="keywords" content="">
	<style type="text/css">
		@import url(default.css);
	</style> <script type="text/javascript">
var gaJsHost = (("https:" == document.location.protocol) ? "https://ssl." : "http://www.");
document.write(unescape("%3Cscript src='" + gaJsHost + "google-analytics.com/ga.js' type='text/javascript'%3E%3C/script%3E"));
</script>
<script type="text/javascript">
var pageTracker = _gat._getTracker("UA-6396952-14");
pageTracker._initData();
pageTracker._trackPageview();
</script>	

<script language="javascript" type="text/javascript">
	// Add the resize function to the page load event
	function smt_fontsizeAddEvent(obj, evType, fn){
		if (obj.addEventListener){
			obj.addEventListener(evType, fn, false);
			return true;
		} else if (obj.attachEvent){
			var r = obj.attachEvent("on"+evType, fn);
			return r;
		} else {
			return false;
		}
	}
	// Triggers a resize on page load 
	smt_fontsizeAddEvent(window, 'load', smt_fontsizeInit);
	// Enables/disables buttons
	function smt_fontsizeBtnStatus(btnId,status){
		btnId = "smt_fontsize_" + btnId;
		
			if(document.getElementById(btnId)){
				document.getElementById(btnId).src='images/smt_fontsize/' + status;
			}
		
	}
	// Initialize the page
	function smt_fontsizeInit(){
		// Compute the font sizes for all tags whose style.fontSize is undefined.
		for(var i=0; element = document.getElementsByTagName("*")[i]; i++){
			element.style.fontSize = smt_fontsizeGetCurrentFontSize(element);
		}
		 // Set the font to the last saved value (in the cookie.)
			if(smt_fontsizeGetCookie() != ""){
				smt_fontsizeIncrement(smt_fontsizeGetCookie(),true);
			} else { // Cookie doesn't exist. Create it and set the font size.
				smt_fontsizeIncrement('0',true);
				smt_fontsizeSetCookie('0');
			}
		
		
			if(smt_fontsizeGetCookie() == 8){
				smt_fontsizeBtnStatus('increase','increase_.gif');
			}
			if(smt_fontsizeGetCookie() == -2){
				smt_fontsizeBtnStatus('decrease','decrease_.gif');
			}
		
	}
	// function to set the value of the cookie.
	function smt_fontsizeSetCookie(value) { 
		var name = "smt_fontsize_relative";
		
		var curCookie = name + "=" + escape(value);
		
		document.cookie = curCookie;
	}
	// function to get the cookie value.
	function smt_fontsizeGetCookie(){
		var name = "smt_fontsize_relative";
		if (document.cookie.indexOf(name) != -1) {
			cs=document.cookie.indexOf(name+"=");
			if(cs!=-1){
				cs=cs + name.length+1;
				ce=document.cookie.indexOf(";",cs);
				if(ce==-1) ce=document.cookie.length
				return parseInt(unescape(document.cookie.substring(cs,ce)));
			} else {
				return "";
			}
		} else {
			return "";
		} 
	}
	// A function to compute the current font size as rendered by the browser.
	function smt_fontsizeGetCurrentFontSize(elem){
		var ieFontScale	=	new Array ("10","11","12","14","18","24","30","36","48","60","72");
		if ( elem == null )
			return null;
		
		// if the style isn't defined inline, then ask the browser to compute the current size	
		if ( elem.style.fontSize == "")
		{
			var browserName=navigator.appName; 
			var browserVer=parseInt(navigator.appVersion); 
			if (browserName=="Microsoft Internet Explorer" && browserVer>=4) 
				//font element was deprecated in HTML 4.01
				//IE does not handle the increments well without this
				if(elem.tagName == "FONT"){
					var ieFontIndex = elem.getAttribute("size");
					if(ieFontIndex == "" || ieFontIndex < 0){
						return '12';
					} else {
						return ieFontScale[ieFontIndex];
					}
				} else {
					return elem.currentStyle.fontSize;
				}
			else
				if(navigator.vendor.indexOf('Apple') != 0){
					return document.defaultView.getComputedStyle(elem, '').getPropertyValue("font-size");
				} else {
					return '12';
				}
		}
		// else return the current fontsize.
		else
		{
			return elem.style.fontSize;
		} 
	}
	// Checks if an element is a child of a filtered node (one that should be resized.)
	function smt_fontsizeParentIsFiltered(elem_temp){
		var elem = elem_temp;
		var classname;
		while ( elem.parentNode != null && elem.parentNode.tagName != "HTML")
		{
			elem = elem.parentNode;
			try
			{
				if ( elem.getAttribute('class') != null )
					classname = elem.getAttribute('class');
				else
					classname = elem.className;
			
				var isResizable = classname.indexOf('content') >= 0;
			
				if (classname == "content" | isResizable)
					return true;
			} catch(err) {/*alert(elem + ": " + err.description + " ");*/}
		}
	
		return false;
	}
	// Increments the fontsize of an element.
	function smt_fontsizeIncrementElement(elem,size){
		var currentSize;
		var currentVal;
		var currentUnit;
		var unitPattern = /[A-Z]+$/i;
		
		
		if ( smt_fontsizeParentIsFiltered(elem) )
		{
		
			currentSize = smt_fontsizeGetCurrentFontSize(elem);
			currentVal = currentSize.substring(0,currentSize.search(unitPattern));
			currentUnit = currentSize.substring(currentSize.search(unitPattern),currentSize.length);

			if ( size + parseFloat(currentVal) > 0)
				elem.style.fontSize = (size + parseFloat(currentVal)) + currentUnit;
		
		}
		
	}
	// Increments the font size of every element on the page by "size."
	// Size can be either +,-,default, or an integer value between the max and min allowed.
	// the dontUpdateCookie flag prevents the function from updating the cookie after the font resize.
	function smt_fontsizeIncrement(size,dontUpdateCookie){
		if( size == "+" )
			size = 2;	
		else if ( size == "-" )
			size = -2;
		else if ( size == "default" ){
			size = -smt_fontsizeGetCookie();
			
				smt_fontsizeBtnStatus('increase','increase.gif');
				smt_fontsizeBtnStatus('decrease','decrease.gif');
			
		}
		else
			size = parseInt(size);
			
		if ( dontUpdateCookie == null )
			smt_fontsizeSetCookie( size + smt_fontsizeGetCookie() );
			
		for ( var i=0; element = document.getElementsByTagName("*")[i]; i++ )
			smt_fontsizeIncrementElement(element,size);
		
		
			if(smt_fontsizeGetCookie() <= -2){
				smt_fontsizeBtnStatus('decrease','decrease_.gif');
			}
			if(smt_fontsizeGetCookie() >= 8){
				smt_fontsizeBtnStatus('increase','increase_.gif');
			}
		
	}
	</script>

				
<script type="text/javascript">
//<!--
var ns4 = (document.layers);
var ie  = (document.all);
var ie4 = (ie && !document.getElementById);
var ie5 = (ie && document.getElementById);
var ns6 = (!ie && document.getElementById);

var aryMoused = new Array();
var aryLayerMoused = new Array();
var aryMoImages = new Array();
var imageList = new Array();
var runMouseOvers = true;
var TimerID = null;
var iLimit = 25;
var itmp = 0;

var nbTime = 100;
var nbTimes = 2;
var nbThisLoc = 325;
var aryLayerNames = new Array();
var aryNavBarLayerInfo = new Array();
var aryNavBarLayers = new Array();

var registeredObjects = new Array();
var viz = "hide";

function MOImage() {
	var arg = MOImage.arguments;
	this.ptrImage = BillzNavBarMM_findObj(arg[0]);
	this.imageMO = new Image();
	this.imageMO.src = arg[1];
	this.HTMLname = arg[0];
	this.Moused = false;
	this.OriginalSrc = '';
	return true;
}

function BillzImagePreload() {
	// 0) html image name 1) mo image src 2)image Name for rollover key (rollover may have multiple mos for one html Image) 
	var arg = BillzImagePreload.arguments;
	nbImagePreload(arg[0], arg[1], arg[2]);
}

function nbImagePreload(img_name, mo_img_src, rollover_key_img_name) {
	var imageKey = (rollover_key_img_name.length > 0) ? rollover_key_img_name : img_name;
	imageList[imageList.length] = imageKey;
	if (!(aryMoImages[imageKey])) aryMoImages[imageKey] = new MOImage(img_name, mo_img_src);
}

function BillzMouseover() {
	var arg = null;
	if (runMouseOvers) {		
		arg = BillzMouseover.arguments; //args 0)ImageName 1)OriginalSrc 2)array index (caller imagename)		
		nbMouseover(arg[0], arg[1], arg[2]);
	}
	return true;
}
// args 1) ImageName 2) OriginalSrc 3) array index (caller imagename)
function nbMouseover(img_name, orig_src, img_key) {
	var imageKey = null;
	var o = null;
	if (runMouseOvers) 
	{				
		imageKey = (img_key.length > 0) ? img_key : img_name;
		if (!(aryMoImages[imageKey].ptrImage)) aryMoImages[imageKey].ptrImage = BillzNavBarMM_findObj(img_name);		
		if (aryMoImages[imageKey] && (o = aryMoImages[imageKey].ptrImage)) {
			aryMoImages[imageKey].OriginalSrc = orig_src;
			aryMoImages[imageKey].Moused = true;
			o.src = aryMoImages[imageKey].imageMO.src;
		}
	}
	return true;
}

var NavBarTempOnload = null;
if (window.onload && window.onload != null) NavBarTempOnload = window.onload;

function FullyLoaded() {
	if (NavBarTempOnload != null) NavBarTempOnload();
	runMouseOvers = true;
	return true;
}

function BillzMouseOutTimer() {
	return nbMouseOutTimer();
}

function nbMouseOutTimer() {
	if (TimerID) clearTimeout(TimerID);
	TimerID = setTimeout("nbLayerRestore()",5000);
	return true;
}

function RestoreAll() {
	nbMouseoverRestore();
	nbLayerRestore();
	return true;
}

function BillzMouseoverRestore() {
	return nbMouseoverRestore();
}

function nbMouseoverRestore() {
	var i = 0;
	var o = null;
	if (runMouseOvers) {
		for (i = 0; i < imageList.length; i++) {
			if (aryMoImages[imageList[i]].Moused && (o = aryMoImages[imageList[i]].ptrImage)) {
				o.src = aryMoImages[imageList[i]].OriginalSrc;
				aryMoImages[imageList[i]].Moused = false;
			}
		}
	}
	return true;
}

function BillzLayerRestore() {
	return nbLayerRestore();
}

function nbLayerRestore() {
	var i = 0;
	for (i = 0; i < aryLayerNames.length; i++) {
		if (!aryNavBarLayerInfo[aryLayerNames[i]].isDefault) BillzNavBarRestoreLayers(aryLayerNames[i]);	
	}
	return true;
}

function BillzArrayPushUnique(aryArray, varNewElement) { //only pushes if unique value
	var pushIt = true;
	var i = 0;
	for (i = 0; i < aryArray.length && pushIt; i++) {
		pushIt = (varNewElement != aryArray[i]);
	}
	if (pushIt) BillzArrayPush(aryArray, varNewElement);
	return pushIt;
}

function BillzArrayPush(aryArray, varNewElement) { //Implement Array Push 'cause IE cant handle it
	aryArray[aryArray.length] = varNewElement;
	return true;
}
function BillzArrayPop(aryArray) { //Implement Array Pop 'cause IE cant handle it before 5.5
	var varItemToPop = null;
	if (aryArray[aryArray.length - 1]) {
		varItemToPop = aryArray[aryArray.length - 1];
		aryArray[aryArray.length] = null;
	}
	return varItemToPop;
}

function getDivRef(id) {
	var divref;
	if(ns4) divref = document.layers[id];
	else if(ie4) divref = document.all[id];
	else if(ie5 || ns6) divref = document.getElementById(id);	
	return divref;
}

//v3.0 name changed to avoid clash with possible other JS in content, this function complements of MM Dreamweaver
function NavBarSwapRollover(swapimage,defaultimage,imageID) {
	if(imageID.length > 0 && document.getElementById(imageID))
	{
		if(swapimage.length > 0) 
			document.getElementById(imageID).src = "images/" + swapimage;
		else
			document.getElementById(imageID).src = "images/" + defaultimage;		
	}
}
function BillzNavBarMM_findObj(n, d) {
	var p,i,x;
	if (ns6) x = document.getElementById(n);
	else {		
		if (registeredObjects[n]) return registeredObjects[n];
		if (!(d)) d = document;
		try {
			p = n.indexOf("?");
		}
		catch(e) {
			p = 0;
		}
		if (p > 0 && parent.frames.length) {
			d = parent.frames[n.substring(p+1)].document;
			n = n.substring(0,p);
		}
		if (!(x = d[n]) && d.all) x = d.all[n];	
		for (i = 0; !x && i < d.forms.length; i++) {
			x = d.forms[i][n];
		}
		for (i=0; !x && d.layers && i < d.layers.length; i++) {
			if (d.layers[i].id.indexOf("external_") == -1) x = BillzNavBarMM_findObj(n, d.layers[i].document);	
		}
		registeredObjects[n] = x;
	}				
	return x;
}

function BillzArrayContains() {
	var arg = BillzArrayContains.arguments;
	var foundit = false;
	var i = 0;
	for (i = 0; i < arg[0].length && !foundit; i++) {
		foundit = (arg[1] == arg[0][i]);
	}
	return foundit;
}

function NavBarRegisterLayer() {
	var arg = NavBarRegisterLayer.arguments;
	var n = arg[0];
	var d = arg[1];
	var mo = false;
	var o = null;
	if (arg[2] && arg[2] == 'MOutLayer') mo = true;
	else mo = false;
	
	if (!(BillzArrayContains(aryLayerNames, n))) {
		if (o = BillzNavBarMM_findObj(n)) {
			aryNavBarLayers[n] = o;
			BillzArrayPushUnique(aryLayerNames, n);
			aryNavBarLayerInfo[n] = new NavBarLayer(n, d, mo);
		}
	}
	return true;
}

function BillzNavBarMM_showHideLayers() {
	//v3.0 name changed, this function complements of MM Dreamweaver with customizations by Bill Heller
	var i = 0;
	var x = "";
	var obj = null;
	var v = null;
	var p = null;
	var args = BillzNavBarMM_showHideLayers.arguments;
	
	if (args[args.length - 1] != "menu") nbMouseOutTimer();
	for (i = 0; i < (args.length - 2); i += 3) {
		if (!aryNavBarLayers[args[i]]) {
			x = (args[i + 2] == 'show') ? 'hide' : 'show';
			NavBarRegisterLayer(args[i], x);
		}
		if ((obj = aryNavBarLayers[args[i]]) != null) {
			v = args[i + 2];
			aryNavBarLayerInfo[args[i]].isDefault = false;
			if (args[args.length - 1] == "restore") v = (v == 'show') ? 'hide' : 'show';
			
			if (obj.style) obj.style.visibility = (v == 'show') ? 'visible' : ((v == 'hide') ? 'hidden' : v);
			else obj.visibility = v;
		}
	}
	return true;
}

function BillzNavBarRestoreLayers() {
	var i = 0;
	var x = "";
	var obj = null;
	var v = null;
	var p = null;
	var args = BillzNavBarRestoreLayers.arguments;
	for (i = 0; i < (args.length); i++) {
		if (obj = aryNavBarLayers[args[i]]) {
			v = aryNavBarLayerInfo[args[i]].defaultVisibility;
			if (obj.style) {
				obj = obj.style;
				v = (v == 'show' ) ? 'visible' : ((v == 'hide') ? 'hidden' : v);
			}
			obj.visibility = v;
			if (!aryNavBarLayerInfo[args[i]].MOutLayer) aryNavBarLayerInfo[args[i]].isDefault = true;			
		}
	}
	return true;
}

function NavBarLayer() {
	var arg = NavBarLayer.arguments;
	this.defaultVisibility = arg[1];
	this.isDefault = true;
	this.MOutLayer = arg[2];
	return true;
}

function BillzNavMove() {
	return nbNavMove();
}

function nbNavMove() {
	var thisl = null;
	var otherl = null;
	if (thisl = BillzNavBarMM_findObj("nbScrollLayer")) {
		if (thisl.style) {
			thisl = thisl.style;
			viz = "hidden";
		} 
		thisl.top = nbThisLoc -= 3;
		if (nbThisLoc < -750) {
			nbThisLoc = 325;
			nbTimes--;
		}
	}
	if (nbTimes <= 0) {
		otherl = BillzNavBarMM_findObj("BillzLayer");
		otherl.visibility = viz;
	} else {
		setTimeout("nbNavMove()", nbTime);
	}	
	return true;
}

function NavBar_openadmin() {
	window.open('admin/','SiteAdmin','height=screen.availheight,width=screen.availwidth,scrollbars=1,toolbar=0,directories=0,status=0,menubar=0,resizable=1');
	return true;
}

window.onload = FullyLoaded;
//-->
</script>
					
<script type="text/javascript">
//<!--
function NavBar_setCookie(cookievalue,navVersion,linkID) 
{	
	var cookiename = "SLIDINGTABLE_NAVBAR" + navVersion;
	var cookieVersionname = "SLIDINGTBL_NAVBAR_VERSION";
	var cookieClear = "SLIDINGTBL_NAVBAR_CLEARCOOKIES";	
	document.cookie = cookieClear.toUpperCase() + "=false";
	if(cookievalue.length > 0)
		document.cookie = cookiename.toUpperCase() + "=" + escape(cookievalue);
	if(navVersion.length > 0)	
		document.cookie = cookieVersionname.toUpperCase() + "=" + navVersion;	
	if(linkID.length > 0)
		NavBar_setPLinkIDCookie(linkID,navVersion);		
}
function NavBar_setoLevelIDCookie(cookievalue,linkID,navVersion) 
{
	var name = "SLIDINGTBL_NAVBAR_OLEVELID";		
	if(cookievalue.length > 0)
		document.cookie = name.toUpperCase() + "=" + escape(cookievalue);	
	if(linkID.length > 0)
		NavBar_setPLinkIDCookie(linkID,navVersion);	
	if(navVersion.length > 0)	
		document.cookie = "SLIDINGTBL_NAVBAR_VERSION=" + navVersion;		
}
function NavBar_setPLinkIDCookie(linkID,navVersion)
{	
	document.cookie = "SLIDINGTBL_NAVBAR_PLINKID=" + linkID;	
	if(navVersion.length > 0)	
		document.cookie = "SLIDINGTBL_NAVBAR_VERSION=" + navVersion;
}
function NavBar_deleteCookie() 
{
	// first we'll split this cookie up into name/value pairs
	// note: document.cookie only returns name=value, not the other components
	var check_name = "SLIDINGTABLE_NAVBAR";	
	var a_all_cookies = document.cookie.split( ';' );
	var a_temp_cookie = '';
	var cookie_name = '';
	var cookie_value = '';
	var b_cookie_found = false; // set boolean t/f default f	

	document.cookie = "SLIDINGTBL_NAVBAR_VERSION=0";	
	document.cookie = "SLIDINGTBL_NAVBAR_OLEVELID=";	
	for (i = 0; i < a_all_cookies.length; i++)
	{		
		a_temp_cookie = a_all_cookies[i].split( '=' );			
		cookie_name = a_temp_cookie[0].replace(/^\s+|\s+$/g, '');
		
		//expire all cookies for every slidingTable_navbar intances.			
		if (cookie_name.toUpperCase().indexOf(check_name) == 0)		
			document.cookie = cookie_name.toUpperCase() + "=";			 	
	}	
}
		
//-->
</script>
			
				
<script type="text/javascript">
//<!--
function NavBar_setCookie(cookievalue,navVersion,linkID) 
{	
	var cookiename = "SLIDINGTABLE_NAVBAR" + navVersion;
	var cookieVersionname = "SLIDINGTBL_NAVBAR_VERSION";
	var cookieClear = "SLIDINGTBL_NAVBAR_CLEARCOOKIES";	
	document.cookie = cookieClear.toUpperCase() + "=false";
	if(cookievalue.length > 0)
		document.cookie = cookiename.toUpperCase() + "=" + escape(cookievalue);
	if(navVersion.length > 0)	
		document.cookie = cookieVersionname.toUpperCase() + "=" + navVersion;	
	if(linkID.length > 0)
		NavBar_setPLinkIDCookie(linkID,navVersion);		
}
function NavBar_setoLevelIDCookie(cookievalue,linkID,navVersion) 
{
	var name = "SLIDINGTBL_NAVBAR_OLEVELID";		
	if(cookievalue.length > 0)
		document.cookie = name.toUpperCase() + "=" + escape(cookievalue);	
	if(linkID.length > 0)
		NavBar_setPLinkIDCookie(linkID,navVersion);	
	if(navVersion.length > 0)	
		document.cookie = "SLIDINGTBL_NAVBAR_VERSION=" + navVersion;		
}
function NavBar_setPLinkIDCookie(linkID,navVersion)
{	
	document.cookie = "SLIDINGTBL_NAVBAR_PLINKID=" + linkID;	
	if(navVersion.length > 0)	
		document.cookie = "SLIDINGTBL_NAVBAR_VERSION=" + navVersion;
}
function NavBar_deleteCookie() 
{
	// first we'll split this cookie up into name/value pairs
	// note: document.cookie only returns name=value, not the other components
	var check_name = "SLIDINGTABLE_NAVBAR";	
	var a_all_cookies = document.cookie.split( ';' );
	var a_temp_cookie = '';
	var cookie_name = '';
	var cookie_value = '';
	var b_cookie_found = false; // set boolean t/f default f	

	document.cookie = "SLIDINGTBL_NAVBAR_VERSION=0";	
	document.cookie = "SLIDINGTBL_NAVBAR_OLEVELID=";	
	for (i = 0; i < a_all_cookies.length; i++)
	{		
		a_temp_cookie = a_all_cookies[i].split( '=' );			
		cookie_name = a_temp_cookie[0].replace(/^\s+|\s+$/g, '');
		
		//expire all cookies for every slidingTable_navbar intances.			
		if (cookie_name.toUpperCase().indexOf(check_name) == 0)		
			document.cookie = cookie_name.toUpperCase() + "=";			 	
	}	
}
		
//-->
</script>
			
				
<script type="text/javascript">
//<!--
function NavBar_setCookie(cookievalue,navVersion,linkID) 
{	
	var cookiename = "SLIDINGTABLE_NAVBAR" + navVersion;
	var cookieVersionname = "SLIDINGTBL_NAVBAR_VERSION";
	var cookieClear = "SLIDINGTBL_NAVBAR_CLEARCOOKIES";	
	document.cookie = cookieClear.toUpperCase() + "=false";
	if(cookievalue.length > 0)
		document.cookie = cookiename.toUpperCase() + "=" + escape(cookievalue);
	if(navVersion.length > 0)	
		document.cookie = cookieVersionname.toUpperCase() + "=" + navVersion;	
	if(linkID.length > 0)
		NavBar_setPLinkIDCookie(linkID,navVersion);		
}
function NavBar_setoLevelIDCookie(cookievalue,linkID,navVersion) 
{
	var name = "SLIDINGTBL_NAVBAR_OLEVELID";		
	if(cookievalue.length > 0)
		document.cookie = name.toUpperCase() + "=" + escape(cookievalue);	
	if(linkID.length > 0)
		NavBar_setPLinkIDCookie(linkID,navVersion);	
	if(navVersion.length > 0)	
		document.cookie = "SLIDINGTBL_NAVBAR_VERSION=" + navVersion;		
}
function NavBar_setPLinkIDCookie(linkID,navVersion)
{	
	document.cookie = "SLIDINGTBL_NAVBAR_PLINKID=" + linkID;	
	if(navVersion.length > 0)	
		document.cookie = "SLIDINGTBL_NAVBAR_VERSION=" + navVersion;
}
function NavBar_deleteCookie() 
{
	// first we'll split this cookie up into name/value pairs
	// note: document.cookie only returns name=value, not the other components
	var check_name = "SLIDINGTABLE_NAVBAR";	
	var a_all_cookies = document.cookie.split( ';' );
	var a_temp_cookie = '';
	var cookie_name = '';
	var cookie_value = '';
	var b_cookie_found = false; // set boolean t/f default f	

	document.cookie = "SLIDINGTBL_NAVBAR_VERSION=0";	
	document.cookie = "SLIDINGTBL_NAVBAR_OLEVELID=";	
	for (i = 0; i < a_all_cookies.length; i++)
	{		
		a_temp_cookie = a_all_cookies[i].split( '=' );			
		cookie_name = a_temp_cookie[0].replace(/^\s+|\s+$/g, '');
		
		//expire all cookies for every slidingTable_navbar intances.			
		if (cookie_name.toUpperCase().indexOf(check_name) == 0)		
			document.cookie = cookie_name.toUpperCase() + "=";			 	
	}	
}
		
//-->
</script>
			</HEAD>
 

<body bgcolor="#9A8454" leftmargin="0" topmargin="0" marginwidth="0" marginheight="0" style="background-image:url(images/vnsm/bkgrd_color.jpg); background-repeat: repeat-x; background-position: top left;">
  <table width="980" border="0" cellpadding="0" cellspacing="0" bgcolor="#9A8454" align="center">
    <tr> 
      <td width="100%" valign="top" align="center" bgcolor="#FFFFFF"><table width="100%" border="0" cellpadding="0" cellspacing="0">
          <tr> 
            <td width="0%" valign="top"><img src="images/vnsm/top_left.gif"></td>
            <td width="100%" valign="top"><img src="images/vnsm/top.gif"></td>
            <td width="0%" valign="top"><img src="images/vnsm/top_right.gif"></td>
          </tr>
        </table></td>
    </tr>
    <tr> 
      <td width="100%" valign="top" bgcolor="#FFFFFF"><table width="100%" border="0" cellpadding="0" cellspacing="0">
          <tr> 
            <td width="0%" valign="top"><img src="images/vnsm/header_left.gif"></td>
            <td width="0%" valign="top" style="background-image: url(images/vnsm/logo_home.gif); background-repeat: no-repeat; background-position: top left;"><a href="default.cfm"><img src="images/vnsm/logo_clear.gif" border="0"></a></td>
            <td width="100%" valign="top"><table width="100%" border="0" cellpadding="0" cellspacing="0">
                <tr> 
                  <td width="100%" valign="top"><table width="100%" border="0" cellpadding="0" cellspacing="0">
                      <tr> 
                        <td width="50%" valign="top" class="date" align="right" style="padding: 7px 0px 0px 0px;"><img src="images/vnsm/tagline.gif"><br>Tue, September 07, 2010 &nbsp; &nbsp;<br><br></td>
                        <td width="100%" valign="top" align="right"><img src="images/vnsm/abovethesearch.gif"><br><br>


	<style name="text/css" class="search">		
		td.search {background-color: transparent; background-image: URL(images/clear.gif); font-family: verdana,arial; font-weight: 700; font-size: 12px; font-color: 000000;}
				
	</style>

		<table border="0" cellpadding="0" cellspacing="0" background="" align= "middle" class="search">		
		<form action="body.cfm?id=16" method="POST">		
		<input type="hidden" name="action" value="list">	
		<input type="hidden" name="search_areas_id" value="">	
		<input type="hidden" name="includewhat" value="">
		<input type="hidden" name="keywords_required" value="You must enter a keyword to search.<br>To search for a specific phrase enclose that phrase in quotes.<br>To search for documents containing all of your keywords simply enter the words.<br><br><a href='javascript:history.back()'>Back</a>">	
			<tr class="search">							
				
					<td class="search">Search&nbsp;&nbsp;</td>
				
				
					<td class="search"><input type="text" name="keywords" size="15" value="Search Intranet"></td>
							
				
					<td class="search"><input type="IMAGE" src="images/go.gif" border="0" width="38" height="24"></td>
				
			</tr>
		</form>
		</table>
	 
<br><br></td>
                      </tr>
                    </table></td>
                </tr>
                <tr> 
                  <td width="100%" valign="top">
										<table width="100%" border="0" cellpadding="0" cellspacing="0">
                      <tr> 
                        <td width="25%" valign="top">


<table cellpadding="0" cellspacing="0" class="smt_fontsize">
	<tr>
	
		<td class="smt_fontsize decrease">
			
				<img class="smt_fontsize" id="smt_fontsize_decrease" src="images/smt_fontsize/decrease.gif" onmouseover="javascript:if(smt_fontsizeGetCookie() > -2){this.src='images/smt_fontsize/decrease_on.gif';}" onmouseout="javascript:if(smt_fontsizeGetCookie() > -2){this.src='images/smt_fontsize/decrease.gif';}else{this.src='images/smt_fontsize/decrease_.gif'};" onclick="javascript:if(smt_fontsizeGetCookie() > -2){smt_fontsizeIncrement('-');smt_fontsizeBtnStatus('increase','increase.gif');smt_fontsizeBtnStatus('default','default.gif');};" alt="Decrease (-)">
			
		</td>			
	
		<td class="smt_fontsize default">
			
				<img class="smt_fontsize" id="smt_fontsize_default" src="images/smt_fontsize/default.gif" onmouseover="javascript:this.src='images/smt_fontsize/default_on.gif';" onmouseout="javascript:this.src='images/smt_fontsize/default.gif';" onclick="javascript:smt_fontsizeIncrement('default');" alt="Restore Default">
			
		</td>
	
		<td class="smt_fontsize increase">
			
				<img class="smt_fontsize" id="smt_fontsize_increase" src="images/smt_fontsize/increase.gif" onmouseover="javascript:if(smt_fontsizeGetCookie() <8){this.src='images/smt_fontsize/increase_on.gif';};" onmouseout="javascript:if(smt_fontsizeGetCookie() <8){this.src='images/smt_fontsize/increase.gif';}else{this.src='images/smt_fontsize/increase_.gif';};" onclick="javascript:if(smt_fontsizeGetCookie() <8){smt_fontsizeIncrement('+');smt_fontsizeBtnStatus('decrease','decrease.gif');smt_fontsizeBtnStatus('default','default.gif');};" alt="Increase (+)">
			
		</td>
	
	
		<td class="smt_fontsize after"><img alt="" src="images/smt_fontsize/caption.gif"></td>
	
	</tr>
</table>
 

</td>
                        <td width="25%" valign="top" class="printEmail">
			<table class="">
				<tr class="">
					<td class="" style="white-space:nowrap;"><a href="blank.cfm?print=yes&amp;id=298" target="_blank" rel="nofollow"><img src="images/vnsm/printthispage.gif" border="0" style="vertical-align:middle;" alt="Print"></a>&nbsp;&nbsp;&nbsp;&nbsp;<a class="metadetail" href="blank.cfm?id=298&amp;displayheader=No&amp;action=templateEmailFriend&amp;originalAction=None" target="_blank" rel="nofollow"><img src="images/vnsm/emailthispage.gif" border="0" style="vertical-align:middle;" alt="Email"></a></td>
				</tr>
			</table>
		  
</td>
                        <td width="25%" valign="top"><script type="text/javascript">if(navigator.appVersion.indexOf("MSIE") > 0){if(parseInt(navigator.appVersion) >= 4){document.write("<img style='cursor:hand;' onclick='window.external.AddFavorite(location.href, document.title);' src=\"images/vnsm/bookmarkthispage.gif\" alt=\"Bookmark this page\">");}}</script></td>
                      </tr>
                    </table>
									</td>
                </tr>
              </table></td>
            <td width="0%" valign="top"><img src="images/vnsm/header_right.gif"></td>
          </tr>
        </table></td>
    </tr>
    <tr> 
      <td width="100%" valign="top" bgcolor="#FFFFFF" style="background-image:url(images/vnsm/topnav_tile.jpg); background-repeat: repeat-x; background-position: top left;"><table width="100%" border="0" cellpadding="0" cellspacing="0">
          <tr> 
            <td width="0%" valign="top"><img src="images/vnsm/topnav_before.jpg"></td>
            <td width="100%" valign="top" align="center" id="topnav" style="padding: 3px 0px 0px 0px;"
><br>
	<!-- Begin NavBar Output  -  Version:  v0.79a 09/30/2006  -->
	
		<!-- Begin NavBar Bar #1 Content Output... -->
		<table  border="0" cellspacing="0" cellpadding="0" onclick="NavBar_deleteCookie();">
	<tr class="topnav">
		<td class="topnav" valign="top" align="left" title=""><a href="body.cfm?id=45"  onClick="NavBar_setPLinkIDCookie('45','');" class="topnav">Hospice</a></td>
		<td class="topnav" valign="top" align="left" title=""><img src="images/vnsm/topnav_line.gif" alt=""></td>
		<td class="topnav" valign="top" align="left" title=""><a href="body.cfm?id=62"  onClick="NavBar_setPLinkIDCookie('62','');" class="topnav">Home Care</a></td>
		<td class="topnav" valign="top" align="left" title=""><img src="images/vnsm/topnav_line.gif" alt=""></td>
		<td class="topnav" valign="top" align="left" title=""><a href="body.cfm?id=403"  onClick="NavBar_setPLinkIDCookie('403','');" class="topnav">Personal Care</a></td>
		<td class="topnav" valign="top" align="left" title=""><img src="images/vnsm/topnav_line.gif" alt=""></td>
		<td class="topnav" valign="top" align="left" title=""><a href="body.cfm?id=47"  onClick="NavBar_setPLinkIDCookie('47','');" class="topnav">Medical Supplies/Equipment</a></td>
		<td class="topnav" valign="top" align="left" title=""><img src="images/vnsm/topnav_line.gif" alt=""></td>
		<td class="topnav" valign="top" align="left" title=""><a href="body.cfm?id=495"  onClick="NavBar_setPLinkIDCookie('495','');" class="topnav">Physician Connection</a></td>
		<td class="topnav" valign="top" align="left" title=""><img src="images/vnsm/topnav_line.gif" alt=""></td>
		<td class="topnav" valign="top" align="left" title=""><a href="body.cfm?id=20"  onClick="NavBar_setPLinkIDCookie('20','');" class="topnav">Careers</a></td>
		<td class="topnav" valign="top" align="left" title=""><img src="images/vnsm/topnav_line.gif" alt=""></td>
		<td class="topnav" valign="top" align="left" title=""><a href="body.cfm?id=35"  onClick="NavBar_setPLinkIDCookie('35','');" class="topnav">McLaren Subsidiaries</a></td>
	</tr>
</table>
	
		<!-- End NavBar Output -->
	 
</td>
            <td width="0%" valign="top"><img src="images/vnsm/topnav_after.jpg"></td>
          </tr>
        </table></td>
    </tr>
    <tr> 
      <td width="100%" bgcolor="#FFFFFF" height="287" valign="top"><table width="100%" border="0" cellpadding="0" cellspacing="0">
          <tr> 
            <td width="0%" valign="top" style="background-image:url(images/vnsm/leftside_tile.gif); background-repeat: repeat-y; background-position: top left;"><table width="100%" border="0" cellpadding="0" cellspacing="0">
                <tr> 
                  <td width="0%" valign="top"><img src="images/vnsm/leftside.jpg"></td>
                </tr>
              </table></td>
            <td width="100%" valign="top"><table width="100%" border="0" cellpadding="0" cellspacing="0">
                <tr> 
                  <td width="0%" valign="top"><table width="100%" border="0" cellpadding="0" cellspacing="0">
				  <tr> 
                        <td valign="top"><table width="100%" border="0" cellpadding="4" cellspacing="0">
                            <tr> 
                              <td width="100%" valign="top" align="left" style="padding: 0px 0px 0px 10px;"><img src="images/vnsm/leftnavspacer.gif"><br><a href="default.cfm"><img src="images/vnsm/btn_home.gif" border="0"></a><a href="javascript:history.back(1)"><img src="images/vnsm/btn_back.gif" border="0"></a></td>
                            </tr>
                          </table></td>
                      </tr>
                      <tr> 
                        <td valign="top"><table width="100%" border="0" cellpadding="4" cellspacing="0">
                            <tr> 
                              <td width="114" valign="top" align="left" style="padding: 10px 0px 0px 10px;">
	<!-- Begin NavBar Output  -  Version:  v0.79a 09/30/2006  -->
	
		<!-- Begin NavBar Bar #2 Content Output... -->
		
	
		<!-- End NavBar Output -->
	 
</td>
                            </tr>
                          </table></td>
                      </tr>
					  <tr> 
                        <td valign="top"><table width="100%" border="0" cellpadding="4" cellspacing="0">
                            <tr> 
                              <td width="100%" valign="top" align="left" style="padding: 0px 0px 0px 10px;"> 

		
<br><style>
			       a.teaser {font-family: verdana; font-size: 11px; color: 000000; font-weight: normal;}
			       a:hover.teaser {font-family: verdana; font-size: 11px; color: 000000; font-weight: normal;}
			       a:visited.teaser {font-family: verdana; font-size: 11px; color: 000000; font-weight: normal;}
			       th.teaser {font-family: verdana; font-size: 11px; color: 0D468D; font-weight: normal;}
			       td.teaser {font-family: verdana; font-size: 11px; color: 0D468D; font-weight: normal;}
			       </style></td>
                            </tr>
                          </table></td>
                      </tr>
                      <tr> 
                        <td height="60" valign="top" style="background-image:url(images/vnsm/quicklinks_bkgrd.gif); background-repeat: no-repeat; background-position: top left;"><table width="100%" border="0" cellpadding="0" cellspacing="0">
                            <tr> 
                              <td width="200" height="60" valign="top" align="center"><br>


			<style type="text/css">
				INPUT.HotLink {border: 0px;}
				SELECT.HotLink {background-color: #FFFFFF;}
				TABLE.HotLink {background-color: transparent;}
				TD.HotLink {background-color: transparent;}
			</style>		
				
		<script language="JavaScript">
		<!--
		function GoToSite1()
		{
			var xxx;
			var zzz;
			zzz=document.hotlink1.SiteURL1;
			xxx=document.hotlink1.SiteURL1.selectedIndex;
			if(zzz[xxx].value.match(/^http/i))
			{
				window.open(zzz[xxx].value);		
			}
			else
			{	
			
				location.href='' + zzz[xxx].value;
								
				return true;
			}	
		}		
		//-->
		</script>		
		
		<table cellspacing="0" class="HotLink">		
		<form name="hotlink1" method="post" action="">
		
			<tr class="HotLink">
				<td valign="top" class="HotLink">
				<select name="SiteURL1" onChange="GoToSite1();" class="HotLink">
					<option value="">Quick Links...</option>
				
					
					<option value="body.cfm?id=459">H1N1 (Swine) Flu</option>
				
					
					<option value="body.cfm?id=200">Immunization Clinics</option>
				
					
					<option value="https://www.mclaren.org/body.cfm?id=350">On-Line Reordering o...</option>
				
					
					<option value="body.cfm?id=320">Sleep Evaluation</option>
				
					
					<option value="body.cfm?id=8">Volunteers</option>
						
				</select>
				
				</td>
			</tr>			
		</form>
		
		</table>	
	
 
<br></td>
                            </tr>
                          </table></td>
                      </tr>
                      <tr> 
                        <td valign="top" style="padding: 0px 0px 0px 8px;"> 
<br><br></td>
                      </tr>
                    </table></td>
					<td width="0%" valign="top"><img src="images/vnsm/shadow.jpg"></td>
                  <td width="100%" valign="top"><table width="100%" border="0" cellpadding="0" cellspacing="0">
                      <tr> 
                        <td width="100%" align="center" valign="top"><table width="100%" border="0" cellpadding="8" cellspacing="0">
                            <tr> 
                              <td width="100%" valign="top"><span class="title">Immunization Clinic Request Form</span></td>
                            </tr>
                          </table></td>
                      </tr>
                      <tr> 
                        <td height="184" valign="top"><table width="100%" border="0" cellpadding="8" cellspacing="0">
                            <tr> 
                              <td width="100%" height="184" valign="top" class="content">							
					

    <style type="text/css">
    <!--
    @import url("module.css");
    -->
    </style>
<script type="text/javascript" src="http://www.mclaren.org/sitemaker/sm_FormValidation.js"></script>
	
	<form name="eform" method="post" action="http://www.mclarenathome.org/body.cfm?xyzpdqabc=0&id=298&action=submiteform" onSubmit="return (sm_ValidateForm(this) && sm_removeALLrequiredhiddenfields(this));" class="metadetail">
	
	
	<table class="metadetail">
	
	
	<tr class="metadetail">
		<td class="metadetail" colspan="2"><span class="required">
		* Indicates required information</span></td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail" colspan="2" style="{text-align:center;}">Company/Organization Information&nbsp;</th>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">Name&nbsp;<span class="required">*</span>&nbsp;</th>
	
		<td class="metadetail">
			<input type="Text" name="eformField_2" class="metadetail" size="35" value="">
			
		
			<input type="Hidden" name="eformField_2_required" class="metadetail" value="Name is required.">
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">Street Address 1&nbsp;<span class="required">*</span>&nbsp;</th>
	
		<td class="metadetail">
			<input type="Text" name="eformField_3" class="metadetail" size="35" value="">
			
		
			<input type="Hidden" name="eformField_3_required" class="metadetail" value="Street Address 1 is required.">
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">Street Address 2&nbsp;</th>
	
		<td class="metadetail">
			<input type="Text" name="eformField_4" class="metadetail" size="35" value="">
			
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">City&nbsp;<span class="required">*</span>&nbsp;</th>
	
		<td class="metadetail">
			<input type="Text" name="eformField_5" class="metadetail" size="35" value="">
			
		
			<input type="Hidden" name="eformField_5_required" class="metadetail" value="City is required.">
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">State&nbsp;<span class="required">*</span>&nbsp;</th>
	
		<td class="metadetail">
			<select name="eformField_6" id="eformField_6" class="metadetail">
				
				<option value="AK" selected>AK</option>
				<option value="AL">AL</option>
				<option value="AR">AR</option>
				<option value="AZ">AZ</option>
				<option value="CA">CA</option>
				<option value="CO">CO</option>
				<option value="CT">CT</option>
				<option value="DC">DC</option>
				<option value="DE">DE</option>
				<option value="FL">FL</option>
				<option value="GA">GA</option>
				<option value="HI">HI</option>
				<option value="IA">IA</option>
				<option value="ID">ID</option>
				<option value="IL">IL</option>
				<option value="IN">IN</option>
				<option value="KS">KS</option>
				<option value="KY">KY</option>
				<option value="LA">LA</option>
				<option value="MA">MA</option>
				<option value="MD">MD</option>
				<option value="ME">ME</option>
				<option value="MI">MI</option>
				<option value="MN">MN</option>
				<option value="MO">MO</option>
				<option value="MS">MS</option>
				<option value="MT">MT</option>
				<option value="NC">NC</option>
				<option value="ND">ND</option>
				<option value="NE">NE</option>
				<option value="NH">NH</option>
				<option value="NJ">NJ</option>
				<option value="NM">NM</option>
				<option value="NV">NV</option>
				<option value="NY">NY</option>
				<option value="OH">OH</option>
				<option value="OK">OK</option>
				<option value="OR">OR</option>
				<option value="PA">PA</option>
				<option value="PR">PR</option>
				<option value="RI">RI</option>
				<option value="SC">SC</option>
				<option value="SD">SD</option>
				<option value="TN">TN</option>
				<option value="TX">TX</option>
				<option value="UT">UT</option>
				<option value="VA">VA</option>
				<option value="VT">VT</option>
				<option value="WA">WA</option>
				<option value="WI">WI</option>
				<option value="WV">WV</option>
				<option value="WY">WY</option>
			</select>
			
			
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">Zip&nbsp;<span class="required">*</span>&nbsp;</th>
	
		<td class="metadetail">
			<input type="Text" name="eformField_7" class="metadetail" size="35" value="">
			
		
			<input type="Hidden" name="eformField_7_required" class="metadetail" value="Zip is required.">
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">County&nbsp;<span class="required">*</span>&nbsp;</th>
	
		<td class="metadetail">
			<input type="Text" name="eformField_8" class="metadetail" size="35" value="">
			
		
			<input type="Hidden" name="eformField_8_required" class="metadetail" value="County is required.">
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail" colspan="2" style="{text-align:center;}">Contact Information&nbsp;</th>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">First Name&nbsp;<span class="required">*</span>&nbsp;</th>
	
		<td class="metadetail">
			<input type="Text" name="eformField_10" class="metadetail" size="35" value="">
			
		
			<input type="Hidden" name="eformField_10_required" class="metadetail" value="First Name is required.">
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">Last Name&nbsp;<span class="required">*</span>&nbsp;</th>
	
		<td class="metadetail">
			<input type="Text" name="eformField_11" class="metadetail" size="35" value="">
			
		
			<input type="Hidden" name="eformField_11_required" class="metadetail" value="Last Name is required.">
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">Contact Phone&nbsp;<span class="required">*</span>&nbsp;</th>
	
		<td class="metadetail">
			<input type="Text" name="eformField_12" class="metadetail" size="35" value="">
			
		
			<input type="Hidden" name="eformField_12_required" class="metadetail" value="Contact Phone is required.">
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">Ext:&nbsp;</th>
	
		<td class="metadetail">
			<input type="Text" name="eformField_13" class="metadetail" size="35" value="">
			
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">Alt Phone&nbsp;</th>
	
		<td class="metadetail">
			<input type="Text" name="eformField_14" class="metadetail" size="35" value="">
			
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">Fax Number&nbsp;</th>
	
		<td class="metadetail">
			<input type="Text" name="eformField_15" class="metadetail" size="35" value="">
			
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">Email Address&nbsp;<span class="required">*</span>&nbsp;</th>
	
		<td class="metadetail">
			<input type="Text" name="eformField_16" class="metadetail" size="35" value="">
			  
			<input type="Hidden" name="eformField_16_email" class="metadetail" value="Email Address must be a valid email address.">
			
		
			<input type="Hidden" name="eformField_16_required" class="metadetail" value="Email Address is required.">
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail" colspan="2" style="{text-align:center;}">Clinic Request&nbsp;</th>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">Estimated Number of Corporate Participants&nbsp;</th>
	
		<td class="metadetail">
			<input type="Text" name="eformField_18" class="metadetail" size="35" value="">
			
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">Estimated Number of Public Participants&nbsp;</th>
	
		<td class="metadetail">
			<input type="Text" name="eformField_19" class="metadetail" size="35" value="">
			
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">Clinic Type&nbsp;</th>
	
		<td class="metadetail">
		
		
			<nobr><input type="checkbox" name="eformField_20" id="eformField_20_1" style="{border:0;}" value="Flu/Pneumonia">
			<label for="eformField_20_1" class="metadetail">Flu/Pneumonia</label></nobr><br>
			
		
			<nobr><input type="checkbox" name="eformField_20" id="eformField_20_2" style="{border:0;}" value="TB(PPD)">
			<label for="eformField_20_2" class="metadetail">TB(PPD)</label></nobr><br>
			
		
			<nobr><input type="checkbox" name="eformField_20" id="eformField_20_3" style="{border:0;}" value="Meningitis">
			<label for="eformField_20_3" class="metadetail">Meningitis</label></nobr><br>
			
		
			<nobr><input type="checkbox" name="eformField_20" id="eformField_20_4" style="{border:0;}" value="Tetanus">
			<label for="eformField_20_4" class="metadetail">Tetanus</label></nobr><br>
			
		
			<nobr><input type="checkbox" name="eformField_20" id="eformField_20_5" style="{border:0;}" value="Hepatitis A">
			<label for="eformField_20_5" class="metadetail">Hepatitis A</label></nobr><br>
			
		
			<nobr><input type="checkbox" name="eformField_20" id="eformField_20_6" style="{border:0;}" value="Hepatitis B">
			<label for="eformField_20_6" class="metadetail">Hepatitis B</label></nobr><br>
			
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">Additional Info:&nbsp;</th>
	
		<td class="metadetail">
			<input type="Text" name="eformField_21" class="metadetail" size="35" value="">
			
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">Please indicate 3 dates and times that would best accommodate you   Date/Time 1&nbsp;</th>
	
		<td class="metadetail">
			<input type="Text" name="eformField_22" class="metadetail" size="35" value="">
			
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">Date/Time 2&nbsp;</th>
	
		<td class="metadetail">
			<input type="Text" name="eformField_23" class="metadetail" size="35" value="">
			
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th valign="top" class="metadetail">Date/Time 3&nbsp;</th>
	
		<td class="metadetail">
			<input type="Text" name="eformField_24" class="metadetail" size="35" value="">
			
		
		</td>
	</tr>
	
	
	<tr class="metadetail">
		<th class="metadetail">&nbsp;</td>
		<td class="metadetail">
			<input type="submit" name="submit" value="Submit" class="metadetail">
		</td>
	</tr>
	
	</table>
	</form>
	

				<br></td>
                            </tr>
                          </table></td>
                      </tr>
                    </table></td>
                </tr>
              </table></td>
            <td width="0%" valign="top" style="background-image:url(images/vnsm/rightside_tile.gif); background-repeat: repeat-y; background-position: top left;"><table width="100%" border="0" cellpadding="0" cellspacing="0">
                <tr> 
                  <td width="0%" valign="top"><img src="images/vnsm/rightside.jpg"></td>
                </tr>
              </table></td>
          </tr>
        </table></td>
    </tr>
    <tr> 
      <td width="100%" valign="top"><table width="100%" border="0" cellpadding="0" cellspacing="0">
          <tr> 
            <td width="0%" valign="top"><img src="images/vnsm/footer_left.jpg"></td>
            <td width="100%" valign="top" style="background-image:url(images/vnsm/footer_tile.jpg); background-repeat: repeat-x; background-position: top left;"><table width="100%" border="0" cellpadding="0" cellspacing="0">
                <tr> 
                  <td width="100%" valign="top" height="45"align="center"><br>
	<!-- Begin NavBar Output  -  Version:  v0.79a 09/30/2006  -->
	
		<!-- Begin NavBar Bar #3 Content Output... -->
		<table  border="0" cellspacing="0" cellpadding="0" onclick="NavBar_deleteCookie();">
	<tr class="">
		<td class="" valign="top" align="center" title=""><a href="body.cfm?id=7"  onClick="NavBar_setPLinkIDCookie('7','');" class="">Maps &amp; Directions</a></td>
		<td class="" valign="top" align="center" title=""><img src="images/vnsm/footerspacer.gif" alt=""></td>
		<td class="" valign="top" align="center" title=""><a href="body.cfm?id=350"  onClick="NavBar_setPLinkIDCookie('350','');" class="">MHC Value Statements</a></td>
		<td class="" valign="top" align="center" title=""><img src="images/vnsm/footerspacer.gif" alt=""></td>
		<td class="" valign="top" align="center" title=""><a href="http://ns1.mclaren.org/gw/webacc"  target="_blank" onClick="NavBar_setPLinkIDCookie('34','');" class="">Groupwise</a></td>
	</tr>
</table>
	
		<!-- End NavBar Output -->
	 
</td>
                </tr>
				<tr>
				  <td valign="top" align="center" bgcolor="#9A8454" class="address">© All rights reserved 2010 McLaren Visiting Nurse & Hospice Corporate Office, 1515 Cal Drive,   Davison, MI   48423   810-496-8676<br><br></td></tr>
              </table></td>
            <td width="0%" valign="top"><img src="images/vnsm/footer_right.jpg"></td>
          </tr>
        </table></td>
    </tr>
  </table>
</body>
</html>