@extends('layouts.applicant')

@section('content')
<div class="row">
	<div class="page-header">
	<h3 style="color:maroon">@if(!empty($message)){{$message}} @endif</h3>
		
	</div>
	
</div>
@if (count($errors) > 0)
    <div class="alert alert-danger">
        <ul>
            @foreach ($errors->all() as $error)
                <li>{{ $error }}</li>
            @endforeach
        </ul>
    </div>
@endif
@if(session('status'))
	<div class="alert alert-success">
		{{session('status')}}
	</div>
@endif

@if(session('statusp'))
	<div class="alert alert-warning">
		{{session('statusp')}}
	</div>
@endif
<form action="{{url('changebiodata')}}" method="POST">
	<div class="row">
		<input type="hidden" name="_token" value="{{csrf_token() }}">
		
	</div>
	<div class="row">
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					First Name 
				</label>
				<input type="text" name="firstname" class="form-control" placeholder="First Name" value="{{$bi->first_name}}"  required>
				
			</div>
			
		</div>
		<div class="col-sm-3">
			<div class="form-group" required>
				<label>
					Middle Name (Optional)
				</label>
				<input type="text" name="middlename" class="form-control" placeholder="Middle Name (Optional)" value="{{$bi->middle_name}}">
				
			</div>
			
		</div>
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					Last Name
				</label>
				<input type="text" name="lastname" class="form-control" placeholder="Last Name" value="{{$bi->last_name}}" required>
				
			</div>
			
		</div>
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					Postal Address
				</label>
				<input type="text" name="postaladdress" class="form-control" placeholder="Postal Address" value="{{$bi->address}}"  required>
				
			</div>
			
		</div>
		
		
	</div>
	<div class="row">
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					Postal Code
				</label>
				<input type="text" name="postalcode" class="form-control" placeholder="Postal Code" value="{{$bi->postal_code}}"  required>
				
			</div>
			
		</div>
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					Town
				</label>
				<input type="text" name="town" class="form-control" placeholder="Town" value="{{$bi->town}}" required>
				
			</div>
			
		</div>
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					Nationality
				</label>
				<select class="form-control" name="nationality" id="nationality">
					<option value="{{$bi->codi}}">{{$bi->full_name}}</option>
					@foreach($country as $c)
					<option value="{{$c->id}}">{{$c->full_name}}</option>

					@endforeach
					
				</select>
				
			</div>
			
		</div>
		<div class="col-sm-3">
				<div class="form-group">
					<label>
						Country Of Examination
					</label>
					<select class="form-control" name="country_of_examination" id="country_of_examination">
						<option value="{{$bi->cexams}}">{{$bi->cnames}}</option>
						@foreach($country as $c)
						<option value="{{$c->id}}">{{$c->full_name}}</option>
	
						@endforeach
						
					</select>
					
				</div>
				
			</div>
		
	</div>
	<div class="row">
			<div class="col-sm-3">
					<div class="form-group">
						<label>
						Gender  <span style="color:red;"> *</span> 
						</label>
						@if($bi->gender=="M")
						
						<div class="radio">
							<label>
								<input type="radio" name="gender" checked id="optionsRadios1" value="M" required="" checked="">Male
							</label>
						</div>
						<div class="radio">
							<label>
								<input type="radio" name="gender" id="optionsRadios2" value="F">Female
							</label>
						</div>
						@else
						
						<div class="radio">
							<label>
								<input type="radio" name="gender" checked id="optionsRadios1" value="M" required="">Male
							</label>
						</div>
						<div class="radio">
							<label>
								<input type="radio" name="gender" id="optionsRadios2" value="F" checked="">Female
							</label>
						</div>
						@endif
								
					</div>
										
				</div>
		<div class="col-sm-3">
			<div class="form-group" required>
				<label id="id_name">
					ID/Birth Cert No.
				</label>
				<input type="text" name="nationalid" class="form-control" placeholder="ID/Birth Cert No." value="{{$bi->id_number}}" id="national_id" required>
				
			</div>
			
		</div>
		<div class="passport">
			@if($bi->valid_passport != "Kenyan Citizen")
			<div class="col-sm-3">
				<div class="form-group"> 
					<label><br /><br>
					</label>
					<input type="radio" {{$bi->valid_passport=="Yes" ? "checked" : ""
				}} name="valid_passport" value="Yes"> My Passport is Valid <br><br>
					<input type="radio" {{$bi->valid_passport=="No" ? "checked" : ""
				}}  name="valid_passport" value="No"> My Passport is invalid
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group">
					<label>Passport Expiry Date</label>
					<input type="text" name="expiry_date" class="form-control datetimepicker" placeholder="Expiry Date" value="{{$bi->expiry_date}}">
				</div>
			</div>
			@endif
			
		</div>
		
	</div>
	
	<div class="row">
			<div class="col-sm-3">
					<div class="form-group" required>
						<label>
							Date of Birth
						</label>
						<input type="text" name="dateofbirth" class="form-control datetimepicker" value="{{$bi->date_of_birth}}" placeholder="Date of Birth" required>
						
					</div>
					
				</div>			
		
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					County
				</label>
				<select class="form-control select2" name="county" id="county">
					<option value="{{$bi->countyId}}">{{$bi->coname}}</option>
					@foreach($county as $c)
					<option value="{{$c->id}}">{{$c->name}}</option>

					@endforeach
					
				</select>
				
			</div>
			
		</div>
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					Sub County
				</label>
				<select class="form-control select2" name="subcounty" id='subcounty'>
					
					<option value="{{$bi->subid}}">{{$bi->subName}}</option>
					
				</select>
				
			</div>
			
		</div>
				
		
		
	</div>
	<div class="row">
			<div class="col-sm-3">
					<div class="form-group">
						<label>
							Constituency
						</label>
						<select class="form-control select2" name="constituency" id="const">
							<option value="{{$bi->consid}}">{{$bi->constname}}</option>
							
							
						</select>
						
					</div>
					
				</div>
		
		<div class="col-sm-3">
			<div class="form-group" required>
				<label>
					Year of Examination
				</label>
				<select class="form-control select2" name="yearofexamination">
					<option value="{{$bi->yearofexam}}">{{$bi->yearofexam}}</option>
										@for($i=$year; $i>=1980; $i--)
					
					<option value="{{ $i }}">{{ $i }}</option>
					@endfor
					
				</select>
				
			</div>
			
		</div>
		<div class="col-sm-3">
			<div class="form-group">
				<label>
				
					Index Number
				</label>
								<input type="text" maxlength="13" name="indexnumber" class="form-control" placeholder="Index Number" value="{{$index}}" required>
				
			</div>
			
		</div>
		<div class="col-sm-3">
			<div class="form-group">
				<label>
				Applicant's	Phone <strong> (e.g.+254712345678)</strong>
				</label>
				<input type="text" name="phone1" class="form-control" maxlength="13" placeholder="Phone Number 1" value="{{$bi->phone}}" required>
				
			</div>
			
		</div>
		
		
	</div>
	<div class="row">
			<div class="col-sm-3">
					<div class="form-group">
						<label>
							Alternative Phone<strong> (e.g.+254712345678)</strong>
						</label>
						<input type="text" name="phone2" class="form-control" maxlength="13" placeholder="Phone Number 2" value="{{$bi->kpho}}" required>
						
					</div>
					
				</div>
	<div class="col-sm-3">
			<div class="form-group">
				<label>
					Name of Next of Kin
				</label>
				<input type="text" name="nameofnextofkin" class="form-control" placeholder="Name of Next of Kin" value="{{$bi->kname}}" required>
				
			</div>
			
		</div>
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					Relationship
				</label>
				<select class="form-control" name="relationship">
					<option value="{{$bi->relation}}">{{$bi->relation}}</option>
					<option value="Brother">Brother</option>
					<option value="Sister">Sister</option>
					<option value="Parent">Parent</option>
					<option value="Guardian">Guardian</option>
					
				</select>
				
			</div>
			
		</div>
		
		
	</div>
	<div class="row" style="background-color:maroon; color:white; padding: 10px 0 10px 0">
		<h5 style="color:white">Disability Assessment</h5>
		<h6 style="color:white">Please note that disability information is required for planning purposes and not creteria for selection</h6>
		
	</div>
	<div class="row" >
		<div class="col-sm-5">
	        <div class="form-group">
                <label>
                Do you consider yourself Disabled person?<span style="color:red;"> *</span> 
                </label>
                @if($bi->disability=="Yes")
                <div class="radio">
                    <label>
                        <input type="radio" name="disability" id="optionsRadios1" value="Yes" checked="" required="">Yes
                    </label>
                </div>
                <div class="radio">
                    <label>
                        <input type="radio" name="disability" id="optionsRadios2" value="No">No
                    </label>
                </div>
                @else
                <div class="radio">
                    <label>
                        <input type="radio" name="disability" id="optionsRadios1" value="Yes" required="">Yes
                    </label>
                </div>
                <div class="radio">
                    <label>
                        <input type="radio" name="disability" id="optionsRadios2" checked="" value="No">No
                    </label>
                </div>

                @endif
	                    
	        </div>
                                
        </div>
       
       
		
		
		
		
	</div>
	<div class="row">
	 <span class="divdisa">
		 <div class="col-sm-2">
	        <div class="form-group">
                <label>
                Type/Class<span style="color:red;"> *</span> 
                </label>
                @if($bi->disability_type=="Physical")
                <div class="radio">
                    <label>
                        <input type="radio" name="disabilitytype" checked="" id="optionsRadios1" value="Physical">Physical
                    </label>
                </div>
                <div class="radio">
                    <label>
                        <input type="radio" name="disabilitytype" id="optionsRadios2" value="Mental">Mental
                    </label>
                </div>
                @elseif($bi->disability_type=="Mental")
                <div class="radio">
                    <label>
                        <input type="radio" name="disabilitytype" id="optionsRadios1" value="Physical">Physical
                    </label>
                </div>
                <div class="radio">
                    <label>
                        <input type="radio" name="disabilitytype" checked id="optionsRadios2" value="Mental">Mental
                    </label>
                </div>
                @else
                <div class="radio">
                    <label>
                        <input type="radio" name="disabilitytype" id="optionsRadios1" value="Physical">Physical
                    </label>
                </div>
                <div class="radio">
                    <label>
                        <input type="radio" name="disabilitytype" id="optionsRadios2" value="Mental">Mental
                    </label>
                </div>
                @endif
	                    
	        </div>
                                
        </div>
		<div class="col-sm-6">
			<div class="form-group">
				<label>
					Give Details of Nature of Disability<span style="color:red;"> *</span>
				</label>
				<textarea class="form-control" rows="5" name="disabilitydetails">{{$bi->disability_info}}</textarea>
				
			</div>
			
		</div>
		</span>
		
	</div>