@extends('app')



@section('title', ucfirst(__('enrollment')))



@section('head')

<link href="{{ url('resources/assets/admin') }}/css/bootstrap-datepicker.css" rel="stylesheet">

<style>

    .datepicker-days th{

        font-size: 18px;

    }

    .datepicker-days td{

        font-size: 16px;

        color: #000;

    }

    .datepicker-months th{

        font-size: 18px;

    }

    .datepicker-months td{

        font-size: 16px;

        color: #000;

    }

    .datepicker-years th{

        font-size: 18px;

    }

    .datepicker-years td{

        font-size: 16px;

        color: #000;

    }

</style>

@endsection



@section('content')

<!-- Topbar bottom Border Ends--->



<!-- Page Banner Area --->



<div class="container-fluid">



    <div class="row">



        <div class="col-md-12 nlrp">



            <img src="{{ url('resources/assets') }}/images/enroll-banner.jpg" class="img-responsive">



        </div>



    </div>



</div>



<!-- Page Banner Area Ends--->



<!-- Enroll Form Area --->



<div class="container">





    <div class="row"><div class="col-md-12 page-heading"><h2>{!!ucwords(__('enrollment <span>form</span>'))!!}</h2></div></div><br>

<div class="col-md-12" style="text-align: center"><br>
<h4 style="color: #fff; font-family: sans-serif; padding-top: -50px">
1. {{__('create your account')}}<br>
2. {{ucfirst(__('follow the steps - complete the course'))}}<br>
3. {{ucfirst(__('no time limits - leave and return if needed'))}}<br>
4. {{ucfirst(__('upon completion, print out your certificate'))}}<br>
5. {{ucfirst(__('most important - laugh and have fun!'))}}<br><br>
</h4>
</div>



    <div class="row form-section">



        <div class="col-md-12 form-box">

            {!! \Form::open([ 'url' => '/signup', 'class' => 'login-form']) !!}



            <div class="row">



                <div class="col-md-12 form-heading"><h3>{!!strtoupper(__('<span>student</span> information'))!!}</h3></div>

                @include("includes/front_alerts")

            </div>



            <div class="row enroll-form">

                <div class="form-horizontal" >

                    <div class="form-group">

                        <div class="col-sm-3">

                            {{ Form::text('first_name', null ,['class' => 'form-control','id'=>'first_name' ,'placeholder'=>__('first name')]) }}

                        </div>

                        <div class="col-sm-3">

                            {{ Form::text('middle_name', null ,['class' => 'form-control','id'=>'middle_name' ,'placeholder'=>__('middle name')]) }}

                        </div>

                        <div class="col-sm-3">

                            {{ Form::text('last_name', null ,['class' => 'form-control','id'=>'last_name' ,'placeholder'=>__('last name')]) }}

                        </div>

                        {{--div class="col-sm-3">

                            {{ Form::text('suffix', null ,['class' => 'form-control','id'=>'suffix' ,'placeholder'=>'Suffix(Jr.,Sr.,III.,IV.,Etc.)']) }}

                        </div>--}}

                    </div>

                    <div class="form-group">

                        <div class="col-sm-3">

                            {{ Form::email('email', null ,['class' => 'form-control','id'=>'email' ,'placeholder'=>ucfirst(__('email address'))]) }}

                        </div>

                        <div class="col-sm-3">

                            {{ Form::email('confirm_email', null ,['class' => 'form-control','id'=>'confirm_email' ,'placeholder'=>ucfirst(__('confirm email address'))]) }}

                        </div>

                    </div>

                    <div class="form-group">

                        <div class="col-sm-3">

                            {{ Form::text('address', null ,['class' => 'form-control','id'=>'address' ,'placeholder'=>ucfirst(__('address'))]) }}

                        </div>

                        <div class="col-sm-3">

                            {{ Form::text('city', null ,['class' => 'form-control','id'=>'city' ,'placeholder'=>ucfirst(__('city'))]) }}

                        </div>

                        <div class="col-sm-3">

                            {{ Form::text('state', null ,['class' => 'form-control','id'=>'state' ,'placeholder'=>ucfirst(__('state'))]) }}

                        </div>

                        <div class="col-sm-3">

                            {{ Form::text('zip', null ,['class' => 'form-control','id'=>'zip' ,'placeholder'=>ucfirst(__('zip'))]) }}

                        </div>

                    </div>

                    <div class="form-group">

                        <div class="col-sm-6">

                            <label>Date of Birth</label>

                            {{-- {{ Form::text('dob', null ,['class' => 'form-control','id'=>'dob' ,'placeholder'=>'Date of Birth']) }} --}}

                            <div class="row">

                                <div class="col-md-5">

                                    {{-- {{ Form::select('month', ['L' => 'November', 'S' => 'December'],['class' => 'form-control'], array('class' => 'form-control', 'placeholder'=>'Month')) }} --}}

                                    @php 

                                        $months = array("January", "Febuary", "March", "April", "May", "June", "July", "August", "September", "October", "November", "December");

                                        $month_value = "1";

                                    @endphp

                                    <select class="form-control" name="month">

                                            <option value="" disabled selected>{{ucfirst(__('month'))}}</option>

                                        @for($i = 0; $i<count($months); $i++)

                                            <option value="{{ ($i+1) }}"{!! ((int)old("month") == ($i+1) ? ' selected="selected"' : '') !!}>{{ucfirst(__(strtolower($months[$i])))}}</option>

                                        @endfor

                                    </select>

                                </div>

                                <div class="col-md-3">

                                    {{-- {{ Form::select('day', ['L' => 'Large', 'S' => 'Small'],['class' => 'form-control'], array('class' => 'form-control', 'placeholder'=>'Day')) }} --}}

                                    <select class="form-control" name="day">

                                            <option value="" disabled selected>{{ucfirst(__('day'))}}</option>

                                        @for ($no=1; $no <= 31; $no++)

                                            <option value="{{$no}}"{!! ((int)old("day") == $no ? ' selected="selected"' : '') !!}>{{$no}}</option>

                                        @endfor

                                    </select>

                                </div>

                                <div class="col-md-4">

                                    {{-- {{ Form::select('year', ['L' => 'November', 'S' => 'December'],['class' => 'form-control'], array('class' => 'form-control', 'placeholder'=>'Year')) }} --}}

                                    <select class="form-control" name="year">

                                            <option value="" disabled selected>{{ucfirst(__('year'))}}</option>

                                        @for ($year=1910; $year <= date("Y")-15; $year++)

                                            <option value="{{$year}}"{!! ((int)old("year") == $year ? ' selected="selected"' : '') !!}>{{$year}}</option>

                                        @endfor

                                    </select>

                                </div>

                            </div>

                        </div>

                        <div class="col-sm-3">

                            <label>{{ucwords(__('phone number'))}} ({{__('numbers only')}})</label>

                            {{ Form::text('contact', null ,['class' => 'form-control','id'=>'contact' ,'placeholder'=>'EX: 2552322525']) }}

                        </div>
                        @if(!$hide_ssn)
                        <div class="col-sm-3">

                            <label>{{ucwords(__('social security number'))}} ({{__('numbers only')}})</label>

                            {{ Form::text('ssn', null ,['class' => 'form-control','id'=>'ssn' ,'placeholder'=>'EX: 123456789']) }}

                        </div>
                        @endif

                    </div>



                </div>

            </div>







            <div class="row">



                <div class="col-md-12 form-heading"><h3><span>{{strtoupper(__('employer'))}} </span> ({{strtoupper(__('optional'))}})</h3></div>



            </div>



            <div class="row enroll-form">

                <div class="form-horizontal" >







                    <div class="form-group">

                        <div class="col-sm-4">

                            <div class="form-group">

                                <label for="sel1">{{ucwords(__('employer on file'))}}:</label>

                                {{ Form::text('eof', null ,['class' => 'form-control','id'=>'eof' ,'placeholder'=>ucwords(__('employer on file'))]) }}

                            </div>

                        </div>

                        <div class="col-sm-4">

                            <label>{{ucwords(__('your title'))}}:</label>

                            {{ Form::text('title', null ,['class' => 'form-control','id'=>'title' ,'placeholder'=>ucwords(__('your title'))]) }}



                        </div>

                    </div>



                </div>



            </div>









            <div class="row">



                <div class="col-md-12 form-heading"><h3><span>{{strtoupper(__('password'))}}</span></h3></div>



            </div>



            <div class="row enroll-form">

                <div class="form-horizontal" >







                    <div class="form-group">

                        <div class="col-sm-4">

                            <div class="form-group">

                                <label for="sel1">{{ucfirst(__('password'))}}:</label>

                                <input type="password" class="form-control" id="password" name="password" placeholder="{{ucfirst(__('password'))}}">

                            </div>

                        </div>

                        <div class="col-sm-4">

                            <label>{{ucfirst(__('confirm password'))}}:</label>

                            <input type="password" class="form-control" id="c_password" name="c_password" placeholder={{ucfirst(__('confirm password'))}}">



                        </div>

                    </div>



                </div>

                <div class="form-group">        



                    <div class="col-sm-12 enroll-btn">

                        <button type="submit" class="btn btn-default">{{ucwords(__('create my account'))}}</button>

                    </div>

                </div>

            </div>

            {!! FORM::close() !!}   





        </div>



    </div>





</div>



<!-- Enroll Form Area Ends --->





@endsection





@section('foot')

<script type="text/javascript" src="{{ url('resources/assets') }}/js/bootstrap.min.js"></script>

<script type="text/javascript" src="{{ url('resources/assets') }}/js/signup.js"></script>

<script src="{{ url('resources/assets/admin') }}/plugins/bootstrap-datepicker.js"></script>

<script >var Globals =