Orthodox Intent Form
// Add Shortcode
function custom_shortcode() {
<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width">
<link rel="stylesheet" href="intention-on-baptism-form-styles.css" media="screen">
<link rel="stylesheet" type="text/css" href="baptism-form-styles.css" media="print" />
<link href="https://fonts.googleapis.com/css?family=Arimo&display=swap" rel="stylesheet">
<link href="https://fonts.googleapis.com/css?family=Roboto+Slab:300,400,700&display=swap&subset=cyrillic" rel="stylesheet">
<title>Orthodox Baptism Form</title>
</head>
<body>
<div class="orthodox-baptism-form-container">
<div class="orthodox-baptism-form-inner-container">
<div class="header-container">
<img class="header-logo" src="images/logo-black.jpg" />
<p>CHURCH OF OUR LADY'S DORMITION<br>
Dandenong Parish of the Russian Orthodox Church<br>
Outside Russia (ROCOR)</p>
<h1>INTENTION OF BAPTISM FORM</h1>
<h6>Please complete in both English and Russian and press the <span>SUBMIT</span> button below:</h6>
</div>
<form class="orthodox-baptism-form">
<div class="row grouped-row">
<div class="row contact-name-row">
<label class="required" for="contact-name">Contact:</label>
<input id="contact-name" class="input" name="contact-name" type="text" value="" placeholder="Name to Contact" />
</div>
<div class="row contact-number-row">
<label class="required" for="contact-number">Phone/Mobile:</label>
<input id="contact-number" class="input" name="contact-number" type="text" value="" placeholder="0548-165-415" />
</div>
</div>
<div class="row grouped-row">
<div class="row address-row">
<label class="required" for="address">Address:</label>
<input id="address" class="input" name="address" type="text" value="" placeholder="20 Smith Street" />
</div>
<div class="row suburb-row">
<label class="required" for="suburb">Suburb:</label>
<input id="suburb" class="input" name="suburb" type="text" value="" placeholder="Clayton" />
</div>
</div>
<div class="row grouped-row">
<div class="row postcode-row">
<label class="required" for="postcode">Postcode:</label>
<input id="postcode" class="input" name="postcode" type="text" value="" placeholder="3175" />
</div>
<div class="row state-row">
<label class="required" for="state">State:</label>
<select id="state" class="select" name="state">
<option value="VIC">Victoria</option>
<option value="NSW">New South Wales</option>
<option value="WA">Western Australia</option>
<option value="QLD">Queensland</option>
<option value="SA">South Australia</option>
<option value="TAS">Tasmania</option>
<option value="ACT">Australian Capital Territory</option>
</select>
</div>
</div>
<div class="row grouped-row">
<div class="row baptism-date-row">
<label class="required" for="baptism-date">Date Of Baptism:</label>
<input id="baptism-date" class="input" name="baptism-date" type="text" value="" placeholder="dd/mm/yyyy" />
</div>
<div class="row baptism-time-row">
<label class="required" for="baptism-time">Time:</label>
<select id="baptism-time" class="select" name="baptism-time">
<option value="09:00">09:00</option>
<option value="09:30">09:30</option>
<option value="10:00">10:00</option>
<option value="10:30">10:30</option>
<option value="11:00">11:00</option>
<option value="11:30">11:30</option>
<option value="12:00">12:00</option>
<option value="12:30">12:30</option>
<option value="13:00">13:00</option>
<option value="13:30">13:30</option>
<option value="14:00">14:00</option>
<option value="14:30">14:30</option>
<option value="15:00">15:00</option>
<option value="15:30">15:30</option>
<option value="16:00">16:00</option>
<option value="16:30">16:30</option>
<option value="17:00">17:00</option>
</select>
</div>
</div>
<div class="row grouped-row">
<div class="row language-row">
<label class="required" for="language">Serv/Lang:</label>
<select id="language" class="select" name="language">
<option value="Eng">English</option>
<option value="Rus">Russian</option>
<option value="Eng & Rus">English & Russian</option>
</select>
</div>
<div class="row email-row">
<label class="required" for="email">Е-mail:</label>
<input id="email" class="input" name="email" type="text" value="" placeholder="[email protected]" />
</div>
</div>
<div class="row-separator"></div>
<div class="form-languages">
<!–– English Language ––>
<div class="form-container form-english">
<div class="form-inner-container">
<h3>Child:</h3>
<div class="row child-surname-row">
<label class="required" for="child-surname">Surname:</label>
<input id="child-surname" class="input" name="child-surname" type="text" value="" placeholder="Family Name" />
</div>
<div class="row child-name-row">
<label class="required" for="child-name">Given Name:</label>
<input id="child-name" class="input" name="child-name" type="text" value="" placeholder="Name" />
</div>
<div class="row sex-row">
<label class="required" for="sex">Sex:</label>
<select id="sex" class="select" name="sex">
<option value="Male">Male</option>
<option value="Female">Female</option>
</select>
</div>
<div class="row dob-row">
<label class="required" for="dob">DOB:</label>
<input id="dob" class="input" name="dob" type="text" value="" placeholder="dd/mm/yyyy" />
</div>
<div class="row birt-place-row">
<label class="required" for="birt-place">Place of Birth (Hospital)</label>
<input id="birt-place" class="input" name="birt-place" type="text" value="" placeholder="Clayton Hospital" />
</div>
<div class="row suburb-row">
<label class="required" for="suburb">(Suburb)</label>
<input id="suburb" class="input" name="suburb" type="text" value="" placeholder="Clayton" />
</div>
<h3>Father:</h3>
<div class="row father-surname-row">
<label class="required" for="father-surname">Surname:</label>
<input id="father-surname" class="input" name="father-surname" type="text" value="" placeholder="Father's Surname" />
</div>
<div class="row father-name-row">
<label class="required" for="father-name">Given Name:</label>
<input id="father-name" class="input" name="father-name" type="text" value="" placeholder="Father's Name" />
</div>
<div class="row father-religion-row">
<label class="required" for="father-religion">Religion:</label>
<select id="father-religion" class="select" name="father-religion">
<option value="Orthodox">Orthodox</option>
<option value="Christianity">Christianity (all others)</option>
<option value="Islam">Islam</option>
<option value="Buddhism">Buddhism</option>
<option value="Hinduism">Hinduism</option>
<option value="Judaism">Judaism</option>
<option value="Atheist">Atheist</option>
<option value="Other">Other</option>
</select>
</div>
<h3>Mother:</h3>
<div class="row mother-surname-row">
<label class="required" for="mother-surname">Maiden name:</label>
<input id="mother-surname" class="input" name="mother-surname" type="text" value="" placeholder="Mother's Maiden Surname" />
</div>
<div class="row mother-name-row">
<label class="required" for="mother-name">Given Name:</label>
<input id="mother-name" class="input" name="mother-name" type="text" value="" placeholder="Mother's Name" />
</div>
<div class="row mother-religion-row">
<label class="required" for="mother-religion">Religion:</label>
<select id="mother-religion" class="select" name="mother-religion">
<option value="Orthodox">Orthodox</option>
<option value="Christianity">Christianity (all others)</option>
<option value="Islam">Islam</option>
<option value="Buddhism">Buddhism</option>
<option value="Hinduism">Hinduism</option>
<option value="Judaism">Judaism</option>
<option value="Atheist">Atheist</option>
<option value="Other">Other</option>
</select>
</div>
<h3>Sponsors <span>(must be Orthodox)</span>:</h3>
<div class="row godfather-row">
<label class="required" for="godfather">Godfather:</label>
<input id="godfather" class="input" name="godfather" type="text" value="" placeholder="Full Name" />
</div>
<div class="row godmother-row">
<label class="required" for="godmother">Godmother:</label>
<input id="godmother" class="input" name="godmother" type="text" value="" placeholder="Full Name" />
</div>
</div>
</div>
<!–– Russian Language ––>
<div class="form-container form-russian">
<div class="form-inner-container">
<h3>Ребенок:</h3>
<div class="row child-surname-row">
<label class="required" for="child-surname">Фамилия:</label>
<input id="child-surname" class="input" name="child-surname" type="text" value="" placeholder="Фамилия" />
</div>
<div class="row child-name-row">
<label class="required" for="child-name">Имя:</label>
<input id="child-name" class="input" name="child-name" type="text" value="" placeholder="Имя" />
</div>
<div class="row sex-row">
<label class="required" for="sex">Пол:</label>
<select id="sex" class="select" name="sex">
<option value="Male">Муж</option>
<option value="Female">Жен</option>
</select>
</div>
<div class="row dob-row">
<label class="required" for="dob">Дата/Рож:</label>
<input id="dob" class="input" name="dob" type="text" value="" placeholder="dd/mm/yyyy" />
</div>
<div class="row birt-place-row">
<label class="required" for="birt-place">Место рождения (Больница)</label>
<input id="birt-place" class="input" name="birt-place" type="text" value="" placeholder="Название Госпиталя" />
</div>
<div class="row suburb-row">
<label class="required" for="suburb">(Город)</label>
<input id="suburb" class="input" name="suburb" type="text" value="" placeholder="Город" />
</div>
<h3>Отец:</h3>
<div class="row father-surname-row">
<label class="required" for="father-surname">Фамилия:</label>
<input id="father-surname" class="input" name="father-surname" type="text" value="" placeholder="Фамилия отца" />
</div>
<div class="row father-name-row">
<label class="required" for="father-name">Имя:</label>
<input id="father-name" class="input" name="father-name" type="text" value="" placeholder="Имя отца" />
</div>
<div class="row father-religion-row">
<label class="required" for="father-religion">Религия:</label>
<select id="father-religion" class="select" name="father-religion">
<option value="Orthodox">Orthodox</option>
<option value="Christianity">Christianity (all others)</option>
<option value="Islam">Islam</option>
<option value="Buddhism">Buddhism</option>
<option value="Hinduism">Hinduism</option>
<option value="Judaism">Judaism</option>
<option value="Atheist">Atheist</option>
<option value="Other">Other</option>
</select>
</div>
<h3>Мать:</h3>
<div class="row mother-surname-row">
<label class="required" for="mother-surname">Дев.Фамилия</label>
<input id="mother-surname" class="input" name="mother-surname" type="text" value="" placeholder="Девичьи Фамилия матери" />
</div>
<div class="row mother-name-row">
<label class="required" for="mother-name">Имя:</label>
<input id="mother-name" class="input" name="mother-name" type="text" value="" placeholder="Имя матере" />
</div>
<div class="row mother-religion-row">
<label class="required" for="mother-religion">Религия:</label>
<select id="mother-religion" class="select" name="mother-religion">
<option value="Orthodox">Orthodox</option>
<option value="Christianity">Christianity (all others)</option>
<option value="Islam">Islam</option>
<option value="Buddhism">Buddhism</option>
<option value="Hinduism">Hinduism</option>
<option value="Judaism">Judaism</option>
<option value="Atheist">Atheist</option>
<option value="Other">Other</option>
</select>
</div>
<h3>Крестные <span>(православные)</span>:</h3>
<div class="row godfather-row">
<label class="required" for="godfather">Крестный:</label>
<input id="godfather" class="input" name="godfather" type="text" value="" placeholder="Полное Имя" />
</div>
<div class="row godmother-row">
<label class="required" for="godmother">Крестная:</label>
<input id="godmother" class="input" name="godmother" type="text" value="" placeholder="Полное Имя" />
</div>
</div>
</div>
</div>
<div class="row-separator"></div>
<div class="button-container">
<button type="submit" form="form1" value="Submit">Submit</button>
<p id="date"></p>
</div>
</form>
<!–– Bottom Row ––>
<div class="bottom-row">
<p><strong>Note: Essential Preparation for each Baptism</strong></p>
<ol>
<li>Baptismal cross with chain or string; large white bath towel; Baptismal outfit; Baptismal Candles (5 medium size candles can be purchased at church on the day of baptisim)</li>
<li>Godparents must be in current and good standings within an Orthodox Church.</li>
<li>Godparents need to know “The Creed” as this is the essential prayer and what we believe in.</li>
<li>The current Church Of Our Lady's Dormition fees are $ 250.oo AUD per baptism.</li>
</ul>
</div>
</div>
</div>
<script src="javascript.js"></script>
</body>
</html>
}
add_shortcode( '[orthodoxform_intent_form]', 'custom_shortcode' );
Fred Montalvo