MLINC Rewards Program Enrollment

In Progress

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

Skills: MySQL, PHP, Software Architecture, Website Design

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Project ID: #4383168

Awarded to:

Codoc1010

Hi, my team has many expert programmers on Html, CSS, PHP, MySQL, WordPress, Drupal. I sure, we can do your job on time with high quality. Please view my message for detail. Thanks!

$206 USD in 5 days
(21 Reviews)
5.3

5 freelancers are bidding on average $206 for this job

zeke

Dear Customer! I am an expert web developer with over 6 years of experience and very interested in this project. Available to start immediately and finish as soon as possible. My bid is for fast professional service More

$200 USD in 2 days
(148 Reviews)
6.8
dagdya99

Hi, I'm interested to work on your project. Waiting for your reply Thanks Dev

$250 USD in 5 days
(102 Reviews)
6.5
ivan381eu

I can do it fast and reliable (fields verification on client side). Please check private message I sent you.

$200 USD in 2 days
(17 Reviews)
4.8
Excogitifotech

hi reay to start your job.we can do it.

$175 USD in 16 days
(11 Reviews)
3.1