


<form action="" method="post">
  <fieldset> <legend><strong>Details</strong></legend>

    <label>Name:</label>
    <input name="name_c" type="text" size="60" value='' required title="Please enter a name"><br>

    <label>Email:</label>
    <input name="mail" type="email" size="60" value='' required title="Please enter a valid email address"><br>

  </fieldset>

  <fieldset><legend><strong>Reservation</strong></legend>
      <label>Date:</label><br>
        <select name="date_number" required  title="Please select date" style="width:90%;">

                      <option value=1    >Tuesday 31 March at 20h30</option>
                      <option value=2    > Wednesday 1 April at 20h30</option>
                  </select> <br><br>

      <label>Tickets:</label><br>
        <table style="border:0px;border-spacing: 0;border-collapse: collapse;">
         <tr>
           <th style="width:33%;text-align:center;border:0px;padding:0">Non-Student</th>
           <th style="width:33%;text-align:center;border:0px;padding:0">Student</th>
           <th style="width:33%;text-align:center;border:0px;padding:0" >Student + Culture card</th>
         </tr>
        <tr style="height:0;">
          <td style="width:33%;text-align:center;border:0px;padding:0"><small>&euro;14</small></td>
          <td style="width:33%;text-align:center;border:0px;padding:0"><small>&euro;10</small></td>
          <td style="width:33%;text-align:center;border:0px;padding:0"><small>&euro;7</small> </td>
        </tr>
         <tr>
           <td style="width:33%;text-align:center;border:0px"><select name="normal">       <option value=0 >0</option><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> </select> </td>
           <td style="width:33%;text-align:center;border:0px"><select name="student">      <option value=0 >0</option><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> </select> </td>
           <td style="width:33%;text-align:center;border:0px"><select name="student_cult"> <option value=0>0</option><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> </select> </td>
         </tr>
        </table>

    <label>Voluntary donation*:</label>
    <input name="donation" type="number" min="0" step=".01" size="60" value=''><br>
      <small>*If you want, you can make an extra donation either via us or by directly donating to the charity!</small>
  </fieldset>
  <fieldset><legend><strong>Remarks</strong></legend>
    <textarea name="remarks" rows="3" cols="55"></textarea>

  </fieldset>
    <button type="submit" name="mode" value="continue">Continue</button>
</form>
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