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MLINC Rewards Program Enrollment

This project was awarded to Codoc1010 for $206 USD.

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Employer working
Awarded to:
Project Budget
$30 - $250 USD
Total Bids
5
Project Description

I own a restaurant, and we run a rewards program that offers Anniversary and Birthday rewards. We currently use a paper enrollment form. I would like to transform that paper form into an HTML form backed by a MySQL database.

Main Fields (These are hard requirements for enrollment:
Phone Number (US 10 Digit), needs client side error checking/verification of a valid looking phone number. Phone number is the primary key for the record
Street Address, validation of the address would be nice, but not a hard requirement
City
State, needs client side error checking/verification of a valid us state
Zip, needs client side error checking/verification of a valid Zip
Email, needs client side error checking/verification

Secondary Fields for anniversary enrollment (Not required, but need to be tied to the Phone number from the main record)
Primary First and Last Name(required)
Significant Other First and Last Name(Required)
Anniversary Month (Select box)

Secondary Fields for Birthday club enrollment (Not required, but need to be tied to the Phone number from the main record)
First Name and Last Name
Birth Month (Select box)
--- For Birthday club there needs to be a way to add any number of names and birthdays. I think the form should display 3 or so, and something client side in javascript to add another set of fields to the record.

The form needs to be easily formatted to fit our website which is being redesigned.
The form needs to be processed and stored into MySQL [url removed, login to view] compatible tables. The create table syntax should be supplied.

Web server environment is Apache [url removed, login to view] running on Linux ([url removed, login to view] shared hosting)

Web server languages available:
Perl [url removed, login to view] (preferred)
PHP 5.2 (preferred)
Ruby 1.8.7
Python 2.6.6

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