<form action="https://www.dorrinejones.com/wp-content/themes/divi-child/rrr/r.php" class="container" method="post"><!-- [et_pb_line_break_holder] --> <div class="container"><!-- [et_pb_line_break_holder] --> <br><!-- [et_pb_line_break_holder] --> <div class="row"><!-- [et_pb_line_break_holder] --> <div class="col-sm-12 col-md-4"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <!-- <label for="date_input">Date</label> --><!-- [et_pb_line_break_holder] --> <input type="date" name="date" required="required" class="form-control" id="date_input" aria-describedby="emailHelp" placeholder="Date"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <div class="row"><!-- [et_pb_line_break_holder] --> <div class="col"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <!-- <label for="FirstName" class="hide">First Name</label> --><!-- [et_pb_line_break_holder] --> <input type="text" name="fname" required="required" class="form-control" id="FirstName" aria-describedby="emailHelp" placeholder="First Name"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-sm-12 col-md-4"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <!-- <label for="MiddleInitial" class="hide">Middle Initial</label> --><!-- [et_pb_line_break_holder] --> <input type="text" name="mname" required="required" class="form-control" id="MiddleInitial" aria-describedby="emailHelp" placeholder="Middle Initial"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-sm-12 col-md-4"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <!-- <label for="LastName" class="hide">Last Name</label> --><!-- [et_pb_line_break_holder] --> <input type="text" name="lname" required="required" class="form-control" id="LastName" aria-describedby="emailHelp" placeholder="Last Name"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <div class="row"><!-- [et_pb_line_break_holder] --> <div class="col-sm-12"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <!-- <label for="Address" class="hide">Address</label> --><!-- [et_pb_line_break_holder] --> <input type="text" name="address" required="required" class="form-control" id="Address" aria-describedby="emailHelp" placeholder="Address"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <div class="row"><!-- [et_pb_line_break_holder] --> <div class="col-sm-12 col-md-4"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <!-- <label for="City" class="hide">City</label> --><!-- [et_pb_line_break_holder] --> <input type="text" name="city" required="required" class="form-control" id="City" aria-describedby="emailHelp" placeholder="City"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-sm-12 col-md-4"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <!-- <label for="State" class="hide">State</label> --><!-- [et_pb_line_break_holder] --> <input type="text" name="state" required="required" class="form-control" id="State" aria-describedby="emailHelp" placeholder="State"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-sm-12 col-md-4"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <!-- <label for="Zip" class="hide">Zip</label> --><!-- [et_pb_line_break_holder] --> <input type="text" name="zip" required="required" class="form-control" id="Zip" aria-describedby="emailHelp" placeholder="Zip"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <div class="row"><!-- [et_pb_line_break_holder] --> <div class="col-sm-12 col-md-6"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <!-- <label for="CP" class="hide">Phone (Cell)</label> --><!-- [et_pb_line_break_holder] --> <input type="tel" required="required" name="phonec" class="form-control" id="CP" aria-describedby="emailHelp" placeholder="Phone (Cell)"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-sm-12 col-md-6"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <!-- <label for="PhoneHome" class="hide">Phone (Home)</label> --><!-- [et_pb_line_break_holder] --> <input type="tel" required="required" name="phoneh" class="form-control" id="phoneHome" aria-describedby="emailHelp" placeholder="Phone (Home)"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <div class="row"><!-- [et_pb_line_break_holder] --> <div class="col-sm-12"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <!-- <label for="exampleInputEmail1">Email address</label> --><!-- [et_pb_line_break_holder] --> <input type="email" class="form-control" id="email" aria-describedby="emailHelp" placeholder="Email"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><!-- <!-- [et_pb_line_break_holder] --> <div class="col-sm-12"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <label for="exampleInputEmail1">Email address</label><!-- [et_pb_line_break_holder] --> <input type="email" class="form-control" id="ConfirmEmail" aria-describedby="emailHelp" placeholder="Email"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> --><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <div class="row"><!-- [et_pb_line_break_holder] --> <div class="col-sm-12"><!-- [et_pb_line_break_holder] --> <b style="margin-bottom: 10px;">Payment Information</b><!-- [et_pb_line_break_holder] --> <table class="table table-bordered"><!-- [et_pb_line_break_holder] --> <tbody><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td>Registration</td><!-- [et_pb_line_break_holder] --> <td>$100</td><!-- [et_pb_line_break_holder] --> <td><input type="checkbox" id="registration" value="Registration - (Non Refundable Due by Febuary 1, 2018)" aria-label="..."></td><!-- [et_pb_line_break_holder] --> <td>(Non Refundable Due by Febuary 1, 2018)</td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td>Pay In Full</td><!-- [et_pb_line_break_holder] --> <td>$475</td><!-- [et_pb_line_break_holder] --> <td><input type="checkbox" id="single" value="Pay In Full - Single Occupancy" aria-label="..."></td><!-- [et_pb_line_break_holder] --> <td>Single Occupancy</td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td>Pay In Full</td><!-- [et_pb_line_break_holder] --> <td>$325</td><!-- [et_pb_line_break_holder] --> <td><input type="checkbox" id="double" value="Pay In Full - Double Occupancy" aria-label="..."></td><!-- [et_pb_line_break_holder] --> <td>Double Occupancy</td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> </tbody><!-- [et_pb_line_break_holder] --> </table><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <div class="row" id="singleOccupancy" style="display: none;"><!-- [et_pb_line_break_holder] --> <div class="col-sm-12"><!-- [et_pb_line_break_holder] --> <b style="margin-bottom: 10px;">Payment Available Only After Paid Registration (Check Your Payment Block) Single Occupancy</b><!-- [et_pb_line_break_holder] --> <table class="table table-bordered"><!-- [et_pb_line_break_holder] --> <tbody><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td>$100</td><!-- [et_pb_line_break_holder] --> <td>Febuary 15, 2018</td><!-- [et_pb_line_break_holder] --> <td><input type="checkbox" id="singleFeb1518" value="Febuary 15, 2018" aria-label="..."></td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td>$100</td><!-- [et_pb_line_break_holder] --> <td>Febuary 28, 2018</td><!-- [et_pb_line_break_holder] --> <td><input type="checkbox" id="singleFeb2818" value="Febuary 28, 2018" aria-label="..."></td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td>$125</td><!-- [et_pb_line_break_holder] --> <td>March 15, 2018</td><!-- [et_pb_line_break_holder] --> <td><input type="checkbox" id="singleMarch1518" value="March 15, 2018" aria-label="..."></td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> </tbody><!-- [et_pb_line_break_holder] --> </table><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <div class="row" id="doubleOccupancy" style="display: none;"><!-- [et_pb_line_break_holder] --> <div class="col-sm-12"><!-- [et_pb_line_break_holder] --> <b style="margin-bottom: 10px;">Payment Available Only After Paid Registration (Check Your Payment Block) Double Occupancy</b><!-- [et_pb_line_break_holder] --> <table class="table table-bordered"><!-- [et_pb_line_break_holder] --> <tbody><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td>$100</td><!-- [et_pb_line_break_holder] --> <td>Febuary 15, 2018</td><!-- [et_pb_line_break_holder] --> <td><input type="checkbox" id="doubleFeb1518" value="Febuary 15, 2018" aria-label="..."></td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td>$100</td><!-- [et_pb_line_break_holder] --> <td>Febuary 28, 2018</td><!-- [et_pb_line_break_holder] --> <td><input type="checkbox" id="doubleFeb2818" value="Febuary 28, 2018" aria-label="..."></td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td>$125</td><!-- [et_pb_line_break_holder] --> <td>March 15, 2018</td><!-- [et_pb_line_break_holder] --> <td><input type="checkbox" id="doubleMarch1518" value="March 15, 2018" aria-label="..."></td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> </tbody><!-- [et_pb_line_break_holder] --> </table><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <script><!-- [et_pb_line_break_holder] --> jQuery(document).ready(function($) {<!-- [et_pb_line_break_holder] --> $('#single').on('change', function(){<!-- [et_pb_line_break_holder] --> if($(this).is(":checked")){<!-- [et_pb_line_break_holder] --> $('#singleOccupancy').attr('style', 'display: block;');<!-- [et_pb_line_break_holder] --> } else {<!-- [et_pb_line_break_holder] --> $('#singleOccupancy').attr('style', 'display: none;');<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> });<!-- [et_pb_line_break_holder] --> $('#double').on('change', function(){<!-- [et_pb_line_break_holder] --> if($(this).is(":checked")){<!-- [et_pb_line_break_holder] --> $('#doubleOccupancy').attr('style', 'display: block;');<!-- [et_pb_line_break_holder] --> } else {<!-- [et_pb_line_break_holder] --> $('#doubleOccupancy').attr('style', 'display: none;');<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> });<!-- [et_pb_line_break_holder] --> });<!-- [et_pb_line_break_holder] --> </script><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <div class="row"><!-- [et_pb_line_break_holder] --> <div class="col-sm-12"><!-- [et_pb_line_break_holder] --> <b>PLEASE COMPLETE ONE OF THESES FORMS WITH EACH ADDITIONAL PAYMENT OF YOUR PAYMENT PLAN.</b><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-sm-12"><!-- [et_pb_line_break_holder] --> <b style="text-transform:uppercase;">**Please call us to make credit card purchase.**</b><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-sm-12"> </div><!-- [et_pb_line_break_holder] --> <div class="col-sm-12 col-md-6"><!-- [et_pb_line_break_holder] --> Make Checks Payable To:<!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-sm-12 col-md-6"><!-- [et_pb_line_break_holder] --> Dorrine Jones <br><!-- [et_pb_line_break_holder] --> P.O Box 349 <br><!-- [et_pb_line_break_holder] --> Lincoln University, PA 19352<!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --><input type="hidden" value="mer" name="x"><!-- [et_pb_line_break_holder] --> <div class="col-sm-12"> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <div class="row"><!-- [et_pb_line_break_holder] --> <div class="col"><!-- [et_pb_line_break_holder] --> <button type="submit" type="submit" class="btn btn-primary">Submit</button><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </form>

Contact Info

  •    P.O. Box 349
    Lincoln University, PA 19352
  •    610-566-0457
  •   info@dorrinejones.com

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