@extends('theme_icr_layout')

@section('content')

  <div id="subSlider" class="jsGallery">
    <div class="jsSlideList">
         </div>
    <div class="jsDotList">
    </div>
  </div>

  <div class="pageContainer">
    <div class="bgGraList">
      <div class="bgGraInner">
        <div class="container980">
          <div class="section">
            <h2></h2>
            <div class="txt">
                          </div>
          </div>



<style type="text/css">
.status_message_div{
	position:fixed; 
	width:260px; 
	top:45%;
	left:50%;
	margin-left:-150px;
	background:#fff;
	background:rgba(32, 52, 105, 0.96);
	border-radius:5px;
	font-family:'Pluto', arial, helvetica, sans-serif;
	color:#fff;
	font-size:14px;
	text-align:center;
	display:none;
	padding:20px;
	font-weight:normal
}
</style>


<form name="my_add_form" id="my_add_form" action="{{ URL('home/assessment_form') }}" method="post">
          <div class="contactForm form bookForm">
            <div class="formRow row">
              <div class="col-lg-5 col-sm-4 label">Name of Child*:</div>
              <div class="col-lg-7 col-sm-8"><input type="text" name="child" id="child" value=""/></div>
            </div>
            <div class="formRow row">
              <div class="col-lg-5 col-sm-4 label">Gender of Child*:</div>
              <div class="col-lg-7 col-sm-8"><input type="text" name="gender" id="gender" value=""/></div>
            </div>
            <div class="formRow row">
              <div class="col-lg-5 col-sm-4 label">Child's Date of Birth*:</div>
              <div class="col-lg-7 col-sm-8"><input type="text" name="birth" id="birth" value=""/></div>
            </div>
            <div class="formRow row">
              <div class="col-lg-5 col-sm-4 label">Name of Parent*:</div>
              <div class="col-lg-7 col-sm-8"><input type="text" name="parent" id="parent" value=""/></div>
            </div>
            <div class="formRow row">
              <div class="col-lg-5 col-sm-4 label">Contact Number*:</div>
              <div class="col-lg-7 col-sm-8"><input type="text" name="contact" id="contact" value=""/></div>
            </div>
            <div class="formRow row">
              <div class="col-lg-5 col-sm-4 label">Email Address*:</div>
              <div class="col-lg-7 col-sm-8"><input type="text" name="email" id="email" value=""/></div>
            </div>
            <div class="formRow row">
              <div class="col-lg-5 col-sm-4 label">Preferred Centre*:</div>
              <div class="col-lg-7 col-sm-8">
                <div class="selectWrap">
                                  </div>
              </div>
            </div>
            <div class="formRow row">
              <div class="col-lg-5 col-sm-4 label">Appointment Preference1:</div>
              <div class="col-lg-7 col-sm-8">
                <label class="labelInline"><input type="radio" name="preference1" id="preference1" value="Morning"/>Morning</label>
                <label class="labelInline"><input type="radio" name="preference1" id="preference1" value="Afternoon"/>Afternoon</label>
                <label class="labelInline"><input type="radio" name="preference1" id="preference1" value="Evening"/>Evening</label>
              </div>
            </div>
            <div class="formRow row">
              <div class="col-lg-5 col-sm-4 label">Appointment Preference2:</div>
              <div class="col-lg-7 col-sm-8">
                <label class="labelInline"><input type="radio" name="preference2" id="preference2" value="Morning"/>Morning</label>
                <label class="labelInline"><input type="radio" name="preference2" id="preference2" value="Afternoon"/>Afternoon</label>
                <label class="labelInline"><input type="radio" name="preference2" id="preference2" value="Evening"/>Evening</label>
              </div>
            </div>


            <div class="formRow row">
              <div class="col-lg-5 col-sm-12 label">How did you hear about us?</div>
              <div class="col-lg-7 col-sm-12"><textarea rows="" cols="" name="how" id="how"></textarea></div>
            </div>

            <div class="formRow row">
              <div class="col-lg-7 col-sm-12 floatRight">
                <div class="btnWrap">
			  	<input type="hidden" name="_token" value="{{ csrf_token() }}">
			  	<input type="hidden" name="cen_id" value="{{ $cen_id }}">
                  <span class="btn btnBlueLarge btnBlue" onclick="my_add_form_submit();">SUBMIT</span>
                </div>
              </div>
            </div>


          </div>
</form>
<script type="text/javascript" language="javascript">
function my_add_form_submit(){
	var form_check_state = form_check();
	if( form_check_state ){
		document.getElementById('my_add_form').submit();
	}else{
		return false;
	}
}

function form_check(){ 
	var error_msg = '';
	error_msg += form_field_text_check('child', 'Name of Child');
	error_msg += form_field_text_check('gender', 'Gender of Child');
	error_msg += form_field_text_check('birth', "'Child's Date of Birth");
	error_msg += form_field_text_check('parent', 'Name of Parent');
	error_msg += form_field_text_check('contact', 'Contact Number');
	error_msg += form_email_check('email', 'Email Address');
	
	if( error_msg != '' ){
		$("#error_message").html(error_msg);
		return false;
	}else{
		return true;
	}
}
</script>


        </div>

      </div>
    </div>
  </div>

@endsection