Fix Location field in PHP registration form

I represent the website for a "church" of skeptics and Atheists who have joined together to spread love and good works around the world. Although the name and beliefs (or lack of) of this organization may be controversial to some, the good they do is undeniable. If this is something you have a problem with, feel free to not bid on this job. One of the things visitors to the website can do is apply to be ordained to legally perform weddings. This is done through a form that is hosted on a WordPress page and processes into a backend database where they wait to either be approved or denied. Currently, there is only one field for city & state/province and we need a dedicated field to split them location data up. As of now, when people apply, unless they fill in both we only get 1 piece of info. This often leaves us with an application that includes either city or state and then a zip code. The problem I am having is when I create the new field it seems to break the php processing. I am sure this is a very simple solution for someone who knows more about this than I. [login to view URL]