            <link rel="stylesheet" href="https://www.wecare.org.tw/wp-content/plugins/cms-members18/include/validationEngine.jquery.css" type="text/css" media="screen" title="no title" charset="utf-8" />
            <script src="https://www.wecare.org.tw/wp-content/plugins/cms-members18/include/jquery.js" type="text/javascript"></script>  
                            <script src="https://www.wecare.org.tw/wp-content/plugins/cms-members18/include/jquery.validationEngine-zh_TW.js" type="text/javascript"></script>
                        <script src="https://www.wecare.org.tw/wp-content/plugins/cms-members18/include/jquery.validationEngine.js" type="text/javascript"></script>
	
	<div class="wwm_register_page">
	<form  name="wordpresswave_members_plugin" id="wwm-members-form" method="post" enctype="multipart/form-data">
	<div class="field"><label>會員類別<span class="wwm-star">*</span></label><br /><p><label><input name="plan" type="radio" id="wwm-plan" class="wwm-plan1 validate[required] radio" value="1" /> 醫學會會員</label></p><p><label><input name="plan" type="radio" id="wwm-plan" class="wwm-plan2 validate[required] radio" value="2" /> 一般網站會員</label></p></div>	
	
	    
    
         
    
	<div class="field"><label>帳號</label> <span class="wwm-star">*</span><br />
    <input type="text" name='username' id="wwm-username" autocomplete="off" class="validate[required,custom[noSpecialCaracters],length[3,20]] text-input" value=""   /></label><br/></div>

	
	
	<div class="field"><label>密碼</label> <span class="wwm-star">*</span><br />
	<input type="password" name='pass' autocomplete="off" id="password" class="validate[required,length[6,30]] text-input" value=""  /></label><br />
	
	<label>確認密碼</label> <span class="wwm-star">*</span><br />
	<input type="password" name='pass2' autocomplete="off" id="password2" class="validate[required,confirm[password]] text-input" value=""  /></label></div>
	
        	<div class="field"><label>姓名 <span class="wwm-star">*</span><br />
	<input type="text" name='fname' id="wwm-fname" value=""  class="validate[required,length[3,100]] text-input" /></label><br /></div>
		<div class="field"><label>性別 <span class="wwm-star">*</span><br />
		<input name="gender" type="radio" id="wwm-m" value="m"  class="validate[required] radio"

    />男性</label><label>

	&nbsp;&nbsp;<input name="gender" type="radio" id="wwm-f" value="f"  class="validate[optional] radio" />女性</label>
	</div>

		<div class="field"><label>生日 <span class="wwm-star">*</span></label><br />
	
	<select class="wwm-birthyear" name="birthyear" id="wwm-birthdayyear" >
	<option value="" selected="selected">-年-</option>
	<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
</select>

        <select class="wwm-birthmonth" name="birthmonth" id="wwm-birthmonth" >
	<option value="" selected="selected">-月-</option>
		<option value="01" >一月</option>
		<option value="02" >二月</option>
		<option value="03" >三月</option>
		<option value="04" >四月</option>
		<option value="05" >五月</option>
		<option value="06" >六月</option>
		<option value="07" >七月</option>
		<option value="08" >八月</option>
		<option value="09" >九月</option
		><option value="10" >十月</option>
		<option value="11" >十一月</option>
		<option value="12" >十二月</option>
	</select>

        <select type="text" name='birthday' id="wwm-birthday"  value=""  />
	<option value="" selected="selected" >-日-</option>
	<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
	</select>

	<br /></div>

		<div class="field"><label>服務單位 <span class="wwm-star">*</span><br />
	<input type="text" name='companyname' id="wwm-companye" value=""  class="validate[required,length[4,30]] text-input" /></label><br /></div>

		<div class="field"><label>聯絡電話 <span class="wwm-star">*</span><br />
	<input type="text" name='telephone' id="wwm-phone" value=""  class="validate[required]  text-input"  /></label><br /></div>

		
	<div class="field"><label>信箱 <span class="wwm-star">*</span><br />
	<input type="text" name='email' id="wwm-email" value=""  class="validate[required,custom[email]] text-input" /></label><br /></div>
	
		
	<div class="field"><label>身分</label> <span class="wwm-star">*</span><br/>				<select name="custom-1" id="wwm-customfield-1" />
                
			<option value="" selected="selected">-Select-</option>
			<option value="專科醫師">專科醫師</option>
<option value="護理人員">護理人員</option>
<option value="社工">社工</option>
<option value="其他">其他</option>
</select><br/></div><div class="field"><label>網站權限</label><br/>				<select name="custom-2" id="wwm-customfield-2" />
                
			<option value="" selected="selected">-Select-</option>
			<option value="管理者">管理者</option>
<option value="講師">講師</option>
<option value="學員">學員</option>
</select><br/><small>醫學會會員請務必填寫此欄位資料</small></div><div class="field"><label>訂閱電子報</label> <span class="wwm-star">*</span><br/><label><input name="custom-3" type="radio" id="wwm-customfield-3" value="願意" class="validate[required] radio wwm-customfield-radio" />願意</label><br/><label><input name="custom-3" type="radio" id="wwm-customfield-3" value="不願意" class="validate[required] radio wwm-customfield-radio" />不願意</label><br/>			
            </div><div class="field"><label>身分證字號</label><br/><input name="custom-4" type="text"  id="wwm-customfield-4"  value=""  
			 class="validate[optional] text-input wwm-customfield" /></label><br/>                        </div>        
        <div class="field">
            <label><label>甄審通過日期 </label><br />
		<input name="pass_status" type="radio" id="pass_yes" value="1" class="radio">通過</label><label>

	&nbsp;&nbsp;<input name="pass_status" type="radio" id="pass_no" value="0" class="radio" checked>未通過</label><br />
            
        <div id="pass_date"><select class="wwm-birthyear" name="passyear" id="wwm-passyear" >
                <option value="2000">2000</option><option value="2001">2001</option><option value="2002">2002</option><option value="2003">2003</option><option value="2004">2004</option><option value="2005">2005</option><option value="2006">2006</option><option value="2007">2007</option><option value="2008">2008</option><option value="2009">2009</option><option value="2010">2010</option><option value="2011">2011</option><option value="2012">2012</option><option value="2013">2013</option><option value="2014">2014</option><option value="2015">2015</option><option value="2016">2016</option><option value="2017">2017</option><option value="2018">2018</option><option value="2019">2019</option>                        </select> 年

                        <select class="wwm-passmonth" name="passmonth" id="wwm-passmonth" >
                                                        <option value="1">1</option>
                                                        <option value="2">2</option>
                                                        <option value="3">3</option>
                                                        <option value="4">4</option>
                                                        <option value="5">5</option>
                                                        <option value="6">6</option>
                                                        <option value="7">7</option>
                                                        <option value="8">8</option>
                                                        <option value="9">9</option>
                                                        <option value="10">10</option>
                                                        <option value="11">11</option>
                                                        <option value="12">12</option>
                                                    </select> 月

                        <select type="text" name='passday' id="wwm-passday">
                                                        <option value="1">1</option>
                                                        <option value="2">2</option>
                                                        <option value="3">3</option>
                                                        <option value="4">4</option>
                                                        <option value="5">5</option>
                                                        <option value="6">6</option>
                                                        <option value="7">7</option>
                                                        <option value="8">8</option>
                                                        <option value="9">9</option>
                                                        <option value="10">10</option>
                                                        <option value="11">11</option>
                                                        <option value="12">12</option>
                                                        <option value="13">13</option>
                                                        <option value="14">14</option>
                                                        <option value="15">15</option>
                                                        <option value="16">16</option>
                                                        <option value="17">17</option>
                                                        <option value="18">18</option>
                                                        <option value="19">19</option>
                                                        <option value="20">20</option>
                                                        <option value="21">21</option>
                                                        <option value="22">22</option>
                                                        <option value="23">23</option>
                                                        <option value="24">24</option>
                                                        <option value="25">25</option>
                                                        <option value="26">26</option>
                                                        <option value="27">27</option>
                                                        <option value="28">28</option>
                                                        <option value="29">29</option>
                                                        <option value="30">30</option>
                                                        <option value="31">31</option>
                                        </select> 日
        </div></div>
		
		
	    
    <input type="hidden" name="wwm_form_noncename" id="wwm_noncename" value="190ee441ba" />    <input type="hidden" name='preview' value="0"  />
	<div class="field"><input type="submit" name="submit" value="註冊" id="wwm-submit" /></div>
	
	</p></form></div>
    
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