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<form action="https://www.paypal.com/cgi-bin/webscr"
method="post">
<input type="hidden" name="business" value="paypal@ccappal.org">
<input type="hidden" name="cmd" value="_xclick">
<input type="hidden" name="item_name" value="Cherokee Retreat 2011">
<input type="hidden" name="item_number" value="Cherokee2011">
<input type="hidden" name="option_amount2" value="500.00"> <input type="hidden" name="option_select2" value="private">
<input type="hidden" name="option_amount0" value="200.00"> <input type="hidden" name="option_select0" value="commuter">
<input type="hidden" name="option_amount1" value="350.00">  <input type="hidden" name="option_select1" value="shared">
<table>
<tr><td><input type="hidden" name="on0" value="Room Type">Cost:</td><td>
<select name="os0">
	<option value="commuter">Local Commuter $200.00 USD</option>  
	<option value="shared">Shared Room $350.00 USD</option> 
	<option value="private">Private Room $500.00 USD</option> 
</select> </td></tr>
<!--  
<tr>
 <td> First Name:* </td> <td><input type="text" name="first_name" value="" size="32" maxlength="32"></td>
</tr>

<tr>
 <td> Last Name:* </td> <td><input type="text" name="first_name" value="" size="32" maxlength="64"></td>
</tr>

<tr>
 <td> Address 1:* </td> <td><input type="text" name="address1" value="" size="64" maxlength="100"></td>
</tr>

<tr>
 <td> Address 2: </td> <td><input type="text" name="address2" value="" size="64" maxlength="100"></td>
</tr>

<tr>
 <td> City:* </td> <td><input type="text" name="city" value="" size="40" maxlength="40"></td>
</tr>

<tr>
 <td> State:* </td> <td><input type="text" name="state" value="" size="2" maxlength="2"></td>
</tr>

<tr>
 <td> Zip:* </td> <td><input type="text" name="zip" value="" size="8" maxlength="32"></td>
</tr>
-->
<tr>
 <td> Phone* </td> <td>(<input type="text" name="night_phone_a" value="" size="3" maxlength="">)
 <input type="text" name="night_phone_b" value="" size="3" maxlength="">-
 <input type="text" name="night_phone_c" value="" size="4" maxlength="">
 </td>
</tr>

<tr>
 <td> Demonionation-Religion </td> <td><input type="hidden" name="on1" value="Demonination"><input type="text" name="os1" value="" size="32" maxlength="64"></td>
</tr>

<tr>
 <td> Tribal Affiliation </td> <td><input type="hidden" name="on2" value="Tribe"><input type="text" name="os2" value="None" size="32" maxlength="64"></td>
</tr>

<tr>
 <td> Name of preferred roommate:</td> <td><input type="hidden" name="on3" value="Roommate"><input type="text" name="os3" value="None" size="32" maxlength="64"></td>
</tr>

<tr>
 <td> Smoking Pref:</td> <td><input type="hidden" name="on4" value="Smoking"><input type="radio" name="os4" value="Non-Smoking" CHECKED>Non-Smoking<input type="radio" name="os4" value="Smoking">Smoking</td>
</tr>

<tr>
 <td> Handicap accessible Room?:</td> <td><input type="hidden" name="on5" value="Handicap"><input type="radio" name="os5" value="No" CHECKED>No<input type="radio" name="os5" value="Yes">Yes</td>
</tr>


</table>
<input type="hidden" name="currency_code" value="USD">
<input type="image" src="https://www.paypalobjects.com/en_US/i/btn/btn_buynowCC_LG.gif" border="0" name="submit" alt="PayPal - The safer, easier way to pay online!">
<img alt="" border="0" src="https://www.paypalobjects.com/en_US/i/scr/pixel.gif" width="1" height="1">
</form>