Perpetual Membership Enrollment - Association of the Miraculous Medal

required

1Enrollment

2Certificate

3Shipping

4Review

PM version from URL parameter

Gravity Form Entry ID

this will be filled in with JS as the "title of the page". it comes from a URL parameter "amm_pm_version". it is done as an HTML field instead of a regular input field to keep it from being editable. this is for display only purposes.

Who would you like to enroll?

Enrollment Type*

Individual - $15.00

Couple - $25.00

Individual - $20.00

Couple - $30.00

Individual - $25.00

Couple - $35.00

Family - $50.00

Individual - $20.00

Familia - $40.00

Individual - $22.00

Pareja - $30.00

Name

First Name(s) Last Name

maximum of 25 characters in First name and in Last name also

First Name(s)*

maximum of 25 characters

Last Name*

maximum of 25 characters

Couple name

The person(s) being enrolled is (my)*

The person(s) being enrolled is (are)

Living

Deceased

Date of Death

MM slash DD slash YYYY

Deluxe Perpetual Membership

Certificate

Please select one of the following:

Number of Certificates to Ship (additional postage will apply for 2 or more)*

No Certificate

price message - data field

This field is hidden when viewing the form

count of certificates

this is updated with javascript when the field #122 is clicked to change it's value.

Which certificate image would you like?

Premium-Individual-Perpetual-Membership-Certificate

Please complete the following, if you wish to receive a certificate:

this is used by javascript to save data into during the button click of "no certificate". this keeps any entered values from being lost

certificate count changes- save data

this is used by javascript to save data into during the button click of "no certificate". this keeps any entered values from being lost

Date to appear on certificate*

MM slash DD slash YYYY

Occasion*

Requested By:

Enter text to be engraved on the the certificate or leave blank for no engraving.

Enter text to be printed on a card enclosed with the certificate or leave blank to have no card included.

enter data to be engraved on to certificate or leave blank for no engraving

maximum of 35 characters

enter data to be engraved on to certificate or leave blank for no engraving

maximum of 35 characters

enter data to be engraved on to certificate or leave blank for no engraving

ShippingPlease enter the shipping information for the certificates. One certificate will be shipped to each location.

Recipient 1

Option

Relationship

How is the person receiving the certificate related to the person being enrolled

How many certificates to send to this person?*

Please enter a number from 1 to 11.

cert count ship #1

Title

First Name*

maximum of 25 characters

Last Name*

maximum of 25 characters

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Recipient 2

Relationship

How is the person receiving the certificate related to the person being enrolled

How many certificates to send to this person?*

Please enter a number from 1 to 5.

cert count ship #2

Title

First Name*

maximum of 25 characters

Last Name*

maximum of 25 characters

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Recipient 3

Relationship

How is the person receiving the certificate related to the person being enrolled

How many certificates to send to this person?*

Please enter a number from 1 to 5.

cert count ship #3

Title

First Name*

maximum of 25 characters

Last Name*

maximum of 25 characters

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Recipient 4

Relationship

How is the person receiving the certificate related to the person being enrolled

How many certificates to send to this person?

Please enter a number from 1 to 5.

cert count ship #4

Title

First Name*

maximum of 25 characters

Last Name*

maximum of 25 characters

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Recipient 5

Relationship

How is the person receiving the certificate related to the person being enrolled

How many certificates to send to this person?*

Please enter a number from 1 to 5.

cert count ship #5

Title

First Name*

maximum of 25 characters

Last Name*

maximum of 25 characters

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please review the information below to ensure it is correct.

Certificate Preview

This is updated via the replace_certificate_data function to add the preview and data

Certificate Preview HTML

Subtotal

Untitled

Recipient 1

Recipient 2

Recipient 3

Recipient 4

Recipient 5

Certificate Preview

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