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Show line numbers {{velocity output="false"}} ## #if ($isGuest) $xwiki.ssx.use('data.WebHome')## $xwiki.jsx.use('data.WebHome')## $xwiki.ssx.use('PhenomeCentral.logo')## $xwiki.ssx.use('PhenomeCentral.login')## $xwiki.ssfx.use('uicomponents/widgets/validation/livevalidation.css', true)## $xwiki.jsfx.use('uicomponents/widgets/validation/livevalidation_prototype.js')## #if ("$!{request.get('request')}" == '1') #if ("$!{request.isClinician}" == '' && "$!{request.isScientist}" == '') #set ($missingConfirmation = true) #end #if ("$!{request.firstName}" == '') #set ($missingFirstName = true) #end #if ("$!{request.lastName}" == '') #set ($missingLastName = true) #end #if ("$!{request.affiliation}" == '') #set ($missingAffiliation = true) #end #if ("$!{request.consortium}" == '') #set ($missingConsortium = true) #end #if ("$!{request.email}" == '') #set ($missingEmail = true) #elseif (!$request.email.matches('^([^@\s]+)@((?:[-a-zA-Z0-9]+\.)+[a-zA-Z]{2,})$')) #set ($invalidEmail = true) #end #if (!$missingConfirmation && !$missingFirstName && !$missingLastName && !$missingAffiliation && !$missingConsortium && !$missingEmail && !$invalidEmail) $xwiki.mailsender.sendMessageFromTemplate("PhenomeCentral <noreply@${request.serverName}>", $request.email, ${NULL}, ${NULL}, $context.language, 'PhenomeCentral.RequestAccountMailForRequester', { 'firstName' : $!{request.firstName}, 'lastName' : $!{request.lastName}, 'affiliation' : $!{request.affiliation}, 'consortium' : $!{request.consortium}, 'email' : $!{request.email}, 'website' : $!{request.website}, 'referral' : $!{request.referral}, 'comments' : $!{request.comments}, 'escapetool' : $escapetool }) $xwiki.mailsender.sendMessageFromTemplate("PhenomeCentral <noreply@${request.serverName}>", 'support@phenotips.org', ${NULL}, ${NULL}, $context.language, 'PhenomeCentral.RequestAccountMailForAdmins', { 'firstName' : $!{request.firstName}, 'lastName' : $!{request.lastName}, 'affiliation' : $!{request.affiliation}, 'consortium' : $!{request.consortium}, 'email' : $!{request.email}, 'website' : $!{request.website}, 'referral' : $!{request.referral}, 'comments' : $!{request.comments}, 'isClinician' : $!{request.isClinician}, 'isScientist' : $!{request.isScientist}, 'isContributor' : $!{request.isContributor}, 'escapetool' : $escapetool }) #set ($success = true) #end #end ## #end {{/velocity}} {{velocity}} {{html clean=false wiki=false}} <form id="request" class="xform" action="" method="post"> <h2>Request your PhenomeCentral account</h2> <p><a href='$xwiki.getURL('data.WebHome')'>PhenomeCentral</a> accounts are limited to clinicians and scientists working with rare disorder patients.</p> <div class="contents"> #if ($success) #info("Thank you for your interest in PhenomeCentral. We took note of your request and we will process it shortly. <a href='$xwiki.getURL('data.WebHome')'>Return to homepage</a>") #elseif ("$!{request.get('request')}" == '1') #if ($missingConfirmation) #error('PhenomeCentral is targeted to clinicians and scientists working in the rare disorder community. You should not request an account on PhenomeCentral unless you can confirm that you are a clinician or scientist working with patients affected by rare disorders.') #else #error('Please provide all the required information.') #end #end #if ($success != true) <input type="hidden" name="request" value="1"/> <dl> <dt class="firstName"><label for="firstName" class="required">First name</label></dt> <dd class="firstName"><input type="text" name="firstName" id="firstName" placeholder="First name" class="required" value="$!{escapetool.xml($request.firstName)}"/></dd> <dt class="lastName"><label for="lastName" class="required">Last name</label></dt> <dd class="lastName"><input type="text" name="lastName" id="lastName" placeholder="Last name" class="required" value="$!{escapetool.xml($request.lastName)}"/></dd> <dt><label for="affiliation" class="required">Affiliation</label></dt> <dd><input type="text" name="affiliation" id="affiliation" placeholder="Institution name" class="required" value="$!{escapetool.xml($request.affiliation)}"/></dd> <dt><label for="consortium" class="required">Consortium</label></dt> <dd><label><input type="radio" name="consortium" value="care4rare"#if ("$!{request.consortium}" == 'care4rare') checked="checked"#end/>CARE for RARE</label> <label><input type="radio" name="consortium" value="udp"#if ("$!{request.consortium}" == 'udp') checked="checked"#end/>The NIH Undiagnosed Diseases Program (UDP)</label> <label><input type="radio" name="consortium" value="rdconnect"#if ("$!{request.consortium}" == 'rdconnect') checked="checked"#end/>RD-Connect</label> <label><input type="radio" name="consortium" value="other"#if ("$!{request.consortium}" == 'other' || "$!{request.consortium}" == '') checked="checked"#end/>Other</label></dd> <dt><label for="email" class="required">Email address</label><span class="xHint">The email address where you wish to receive your account information. Please use your institutional email address rather than gmail, yahoo, etc.</span></dt> <dd><input type="text" name="email" id="email" placeholder="name@myhospital.org" class="required" value="$!{escapetool.xml($request.email)}"/></dd> <dt><label for="website">Website</label><span class="xHint">The URL of your institutional website through which we can confirm your affiliation.</span></dt> <dd><input type="text" name="website" id="website" placeholder="www.myhospital.org" value="$!{escapetool.xml($request.website)}"/></dd> <dt><label for="referral">How did you hear about / Who referred you to PhenomeCentral?</label></dt> <dd><input type="text" name="referral" id="referral" value="$!{escapetool.xml($request.referral)}"/></dd> <dt><label for="comments" class="required">Why are you requesting access to PhenomeCentral?</label></dt> <dd><textarea name="comments" id="comments" rows="3" cols="40" class="required">$!{escapetool.xml($request.comments)}</textarea></dd> <dt><label for="isClinician"><input type="checkbox" name="isClinician" id="isClinician" value="Yes"/> I am a clinician who sees rare disorder patients in my practice</label></dt> <dt><label for="isScientist"><input type="checkbox" name="isScientist" id="isScientist" value="Yes"/> I am a scientist affiliated with a government/non-profit research institute with rare disorder patient data</label></dt> <dt><label for="isContributor"><input type="checkbox" name="isContributor" id="isContributor" value="Yes"/> I plan to contribute patient data</label></dt> </dl> <div class="buttons"> <input type="submit" value="Request access" class="button"> <span class="buttonwrapper"><a class="button secondary" href="$xwiki.getURL('data.WebHome')">Cancel and return to homepage</a></span> </div> #end </form> <div class="clearfloats"></div> {{/html}} {{/velocity}}