document.write('<script language="JavaScript1.2" type="text/javascript">');
document.write('function checkform(form) {');
document.write('	if(form.name.value == \'\') {');
document.write('		window.alert("Please enter your name.");');
document.write('		form.name.focus();');
document.write('		return false;');
document.write('	}');
document.write('	if(form.phone.value == \'\' && form.email.value == \'\') {');
document.write('		window.alert("We need either a phone or e-mail address in order to contact you.");');
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document.write('		return false;');
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document.write('	if(form.c1.checked == false && form.c2.checked == false && form.c3.checked == false && form.c4.checked == false && form.c5.checked == false && form.c6.checked == false && form.c7.checked == false && form.c8.checked == false && form.c9.checked == false && form.c10.checked == false && form.c11.checked == false && form.c12.checked == false && form.c13.checked == false && form.c14.checked == false && form.c15.checked == false && form.c16.checked == false) {');
document.write('		window.alert("Please select at least one activity from the list.");');
document.write('		return false;');
document.write('	}');
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document.write('</script>');
document.write('<table align=center border="1"  id="table1" style="border-width: 2px">');
document.write('	<tr>');
document.write('		<td style="border-style: none; border-width: medium" nowrap>140 W. Franklin ');
document.write('		Street, Suite 300<br>');
document.write('		Hagerstown, MD 21740<br>');
document.write('		Ph: (301) 733-2371<br>');
document.write('		Fax: (301) 733 7479<br>');
document.write('		<a href="mailto:reach@myactv.net">reach@myactv.net</a><br>');
document.write('		<a href="http://www.reachcaregivers.org"  target="_blank">www.reachcaregivers.org</a><br>');
document.write('		<td style="border-style: none; border-width: medium">');
document.write('		<img border="0" src="images/Inspire-Volunteer.JPG" width="245" height="265" align="right"></td>');
document.write('	</tr>');
document.write('	<tr>');
document.write('		<td style="border-style: none; border-width: medium" colspan="2">If you can volunteer your services please check below:</td>');
document.write('	</tr>');
document.write('	<tr>');
document.write('		<td style="border-style: none; border-width: medium" colspan="2"><b>');
document.write('		<font color="#FFA100">I am interested in:</font> </b>');
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document.write('			<input type="checkbox" name="c1" style="font-weight: 700"><b>Local medical transportation escort<br></b>');
document.write('			<input type="checkbox" name="c2" style="font-weight: 700"><b>Long distance medical transportation escort<br></b>');
document.write('			<input type="checkbox" name="c3" style="font-weight: 700"><b>Grocery/pharmacy shopping<br></b>');
document.write('			<input type="checkbox" name="c4" style="font-weight: 700"><b>Friendly visitation<br></b>');
document.write('			<input type="checkbox" name="c5" style="font-weight: 700"><b>Telephone reassurance<br></b>');
document.write('			<input type="checkbox" name="c6" style="font-weight: 700"><b>Yard work<br></b>');
document.write('			<input type="checkbox" name="c7" style="font-weight: 700"><b>Meal preparation for homebound<br></b>');
document.write('			<input type="checkbox" name="c8" style="font-weight: 700"><b>Reading mail<br></b>');
document.write('			<input type="checkbox" name="c9" style="font-weight: 700"><b>Assist with letter writing<br></b>');
document.write('			<input type="checkbox" name="c10" style="font-weight: 700"><b>Assist with paperwork<br></b>');
document.write('			<input type="checkbox" name="c11" style="font-weight: 700"><b>Short term respite care<br></b>');
document.write('			<input type="checkbox" name="c12" style="font-weight: 700"><b>Light housekeeping<br></b>');
document.write('			<input type="checkbox" name="c13" style="font-weight: 700"><b>Social activities escort<br></b>');
document.write('			<input type="checkbox" name="c14" style="font-weight: 700"><b>Snow shoveling<br></b>');
document.write('			<input type="checkbox" name="c15" style="font-weight: 700"><b>Minor home repair<br></b>');
document.write('			<input type="checkbox" name="c16" style="font-weight: 700"><b>Crisis intervention Assistant<br></b>');
document.write('			<input type="checkbox" name="c17" style="font-weight: 700"><b>Cold weather shelter volunteer<br></b>');
document.write('			<input type="checkbox" name="c18" style="font-weight: 700"><b>REACH office volunteer<br>');
document.write('			&nbsp;</b><table border="0" id="table2">');
document.write('				<tr>');
document.write('					<td align="right"><b>Name</b></td>');
document.write('					<td>');
document.write('					<input name="name" size="50" tabindex="17" style="font-weight: 700"></td>');
document.write('				</tr>');
document.write('				<tr>');
document.write('					<td align="right"><b>Address</b></td>');
document.write('					<td>');
document.write('					<input name="address" size="50" tabindex="17" style="font-weight: 700"></td>');
document.write('				</tr>');
document.write('				<tr>');
document.write('					<td align="right"><b>City</b></td>');
document.write('					<td nowrap>');
document.write('					<input name="city" size="30" tabindex="17" style="font-weight: 700"><b>State</b><input name="state" size="3" tabindex="17" style="font-weight: 700"><b>Zip</b><input type="zip" name="zip" size="6" tabindex="17" style="font-weight: 700"></td>');
document.write('				</tr>');
document.write('				<tr>');
document.write('					<td align="right"><b>Phone</b></td>');
document.write('					<td>');
document.write('					<input name="phone" size="20" tabindex="17" style="font-weight: 700"></td>');
document.write('				</tr>');
document.write('				<tr>');
document.write('					<td align="right"><b>E-mail</b></td>');
document.write('					<td>');
document.write('					<input name="email" size="50" tabindex="17" style="font-weight: 700"></td>');
document.write('				</tr>');
document.write('			</table>');
document.write('			<p>');
document.write('			<input type="submit" value="Submit REACH Form" name="action">&nbsp; <input type="reset" value="Reset" name="B2"></p>');
document.write('			</p>');
document.write('		</form>');
document.write('		<p align="center"><b><font color="#FFA100">Faith in Action in Washington County</font></b></p>');
document.write('		<p align="center">&quot;We can do no great things - only small things with ');
document.write('		great love.&quot;--Mother Teresa (1910-1997)</p>');
document.write('		<p align="center">Terri Baker - Executive Director, Kevin R Collins - Program Director, Jill Parker - Resource Specialist</p></td>');
document.write('	</tr>');
document.write('</table>');