ꦫꦣꦺꦤ꧀ꦄꦤ꧀ꦠꦱꦺꦤ

PATH: home / lab2454c / healthvalidate.com / resources / views / applicants / dashboard

@extends('layouts.applicant.dashboard')

@section('content')

<div class="inner__from__wrapp personal__information">
    @include('validation.message')
    @include('validation.flashmessage')

@csrf
        <h2>{{ __('messages.applicant_dashboard.myihr.immunization_form.personal_information_heading')}}</h2>
        <div class="row">
            <div class="col-xl-4 col-lg-4 col-md-12">
                <div class="form-group form__group">
                    <label>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.date_of_birth')}}</label>
                    <input type="text" name='date_of_birth' placeholder="DD/MM/YYYY" value="@if(!empty($user->immunization_application->date_of_birth)){{ date('d/m/Y', strtotime($user->immunization_application->date_of_birth)) }}@endif" class="form-control form__control" required>
                </div>
            </div>

<div class="col-xl-8 col-lg-8 col-md-12">
                <div class="form-group form__group">
                    <label>{{__('messages.applicant_dashboard.myihr.immunization_form.frm_field.gender')}}</label><br />

<label>{{__('messages.applicant_dashboard.myihr.immunization_form.frm_field.gender_female')}}</label> <input type="radio" class="travel_ready" name="gender" value="female" @if(!empty($user->immunization_application->gender) && $user->immunization_application->gender == 'female'){{ 'checked="checked"' }}@endif>
                    <label>{{__('messages.applicant_dashboard.myihr.immunization_form.frm_field.gender_male')}}</label> <input type="radio" class="travel_ready" name="gender" value="male" @if(!empty($user->immunization_application->gender) && $user->immunization_application->gender == 'male'){{ 'checked="checked"' }}@endif>
                    <label>{{__('messages.applicant_dashboard.myihr.immunization_form.frm_field.gender_other')}}</label> <input type="radio" class="travel_ready" name="gender" value="other" @if(!empty($user->immunization_application->gender) && $user->immunization_application->gender == 'other'){{ 'checked="checked"' }}@endif>
                </div>
            </div>
        </div>

<h2>{{ __('messages.applicant_dashboard.myihr.immunization_form.contact_information_heading')}}</h2>
        <div class="row">
            <div class="col-xl-4 col-lg-4 col-md-12">
                <div class="form-group form__group">
                    <label>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.phone_number')}}</label>
                    <input type="text" name='phone_no_1' value="@if(!empty($user->immunization_application->phone_no_1)){{ $user->immunization_application->phone_no_1 }}@endif" class="form-control form__control" required>
                </div>
            </div>
            <div class="col-xl-4 col-lg-4 col-md-12">
                <div class="form-group form__group">
                    <label>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.phone_type')}}</label>
                    <select name="phone_no_1_type" class="form-control form__control selectpicker">
                        <option value="mobile" @if(!empty($user->immunization_application->phone_no_1_type) && $user->immunization_application->phone_no_1_type == 'mobile'){{ 'selected' }}@endif >{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.phone_type_mobile')}}</option>
                        <option value="landline" @if(!empty($user->immunization_application->phone_no_1_type) && $user->immunization_application->phone_no_1_type == 'landline'){{ 'selected' }}@endif>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.phone_type_landline')}}</option>
                    </select>
                </div>
            </div>
        </div>

<div class="row">
            <div class="col-xl-4 col-lg-4 col-md-12">
                <div class="form-group form__group">
                    <label>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.optional_phone_number')}}</label>
                    <input type="text" name='phone_no_2' value="@if(!empty($user->immunization_application->phone_no_2)){{ $user->immunization_application->phone_no_2 }}@endif" class="form-control form__control">
                </div>
            </div>
            <div class="col-xl-4 col-lg-4 col-md-12">
                <div class="form-group form__group">
                    <label>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.phone_type')}}</label>
                    <select name="phone_no_2_type" class="form-control form__control selectpicker">
                        <option value="mobile" @if(!empty($user->immunization_application->phone_no_2_type) && $user->immunization_application->phone_no_2_type == 'mobile'){{ 'selected' }}@endif>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.phone_type_mobile')}}</option>
                        <option value="landline" @if(!empty($user->immunization_application->phone_no_2_type) && $user->immunization_application->phone_no_2_type == 'landline'){{ 'selected' }}@endif>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.phone_type_landline')}}</option>
                    </select>
                </div>
            </div>
        </div>

<div class="row">
            <div class="col-xl-4 col-lg-4 col-md-12">
                <div class="form-group form__group">
                    <label>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.optional_phone_number')}}</label>
                    <input type="text" name='phone_no_3' value="@if(!empty($user->immunization_application->phone_no_3)){{ $user->immunization_application->phone_no_3 }}@endif" class="form-control form__control">
                </div>
            </div>
            <div class="col-xl-4 col-lg-4 col-md-12">
                <div class="form-group form__group">
                    <label>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.phone_type')}}</label>
                    <select name="phone_no_3_type" class="form-control form__control selectpicker">
                        <option value="mobile" @if(!empty($user->immunization_application->phone_no_3_type) && $user->immunization_application->phone_no_3_type == 'mobile'){{ 'selected' }}@endif>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.phone_type_mobile')}}</option>
                        <option value="landline" @if(!empty($user->immunization_application->phone_no_3_type) && $user->immunization_application->phone_no_3_type == 'landline'){{ 'selected' }}@endif>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.phone_type_landline')}}</option>
                    </select>
                </div>
            </div>
        </div>

<div class="row">
            <div class="col-xl-4 col-lg-4 col-md-12">
                <div class="form-group form__group">
                    <label>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.optional_phone_number')}}</label>
                    <input type="text" name='phone_no_4' value="@if(!empty($user->immunization_application->phone_no_4)){{ $user->immunization_application->phone_no_4 }}@endif" class="form-control form__control">
                </div>
            </div>
            <div class="col-xl-4 col-lg-4 col-md-12">
                <div class="form-group form__group">
                    <label>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.phone_type')}}</label>
                    <select name="phone_no_4_type" class="form-control form__control selectpicker">
                        <option value="mobile" @if(!empty($user->immunization_application->phone_no_4_type) && $user->immunization_application->phone_no_4_type == 'mobile'){{ 'selected' }}@endif>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.phone_type_mobile')}}</option>
                        <option value="landline" @if(!empty($user->immunization_application->phone_no_4_type) && $user->immunization_application->phone_no_4_type == 'landline'){{ 'selected' }}@endif>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.phone_type_landline')}}</option>
                    </select>
                </div>
            </div>
        </div>

<h2>{{ __('messages.applicant_dashboard.myihr.immunization_form.address_heading')}}</h2>

<div class="row">
            <div class="col-xl-6 col-lg-6 col-md-12">
                <div class="form-group form__group">
                    <label>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.street_address')}}</label>
                    <input type="text" name='street_address' value='@if(!empty($user->immunization_application->street_address)){{ $user->immunization_application->street_address }}@endif' class="form-control form__control" required>
                </div>
            </div>
            <div class="col-xl-6 col-lg-6 col-md-12">
                <div class="form-group form__group">
                    <label>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.apt_suite_unit')}}</label>
                    <input type="text" name='apt_suite_unit' value='@if(!empty($user->immunization_application->apt_suite_unit)){{ $user->immunization_application->apt_suite_unit }}@endif'  class="form-control form__control">
                </div>
            </div>
        </div>

<div class="row">
            <div class="col-xl-4 col-lg-4 col-md-12">
                <div class="form-group form__group">
                    <label>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.city')}}</label>
                    <input type="text" name='city' value='@if(!empty($user->immunization_application->city)){{ $user->immunization_application->city }}@endif' class="form-control form__control" required>
                </div>
            </div>
            <div class="col-xl-4 col-lg-4 col-md-12">
                <div class="form-group form__group">
                    <label>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.zip_code')}}</label>
                    <input type="text" name='zip_code' value='@if(!empty($user->immunization_application->zip_code)){{ $user->immunization_application->zip_code }}@endif' class="form-control form__control" required>
                </div>
            </div>
            <div class="col-xl-4 col-lg-4 col-md-12">
                <div class="form-group form__group">
                    <label>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.county')}}</label>
                    <input type="text" name='county' value='@if(!empty($user->immunization_application->county)){{ $user->immunization_application->county }}@endif' class="form-control form__control" required>
                </div>
            </div>
        </div>

<div class="row">
            <div class="col-xl-6 col-lg-6 col-md-12">
                <div class="form-group form__group">
                    <label>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.state')}}</label>
                    <input type="text" name='state' value='@if(!empty($user->immunization_application->state)){{ $user->immunization_application->state }}@endif' class="form-control form__control" required>
                </div>
            </div>
            <div class="col-xl-6 col-lg-6 col-md-12">
                <div class="form-group form__group">
                    <label>{{ __('messages.applicant_dashboard.myihr.immunization_form.frm_field.country')}}</label>
                    <input type="text" name='country' value='@if(!empty($user->immunization_application->country)){{ $user->immunization_application->country }}@else{{"United States"}}@endif' class="form-control form__control" readonly>
                </div>
            </div>
        </div>
        <input type="submit" value="{{ __('messages.applicant_dashboard.profile.frm_field.submit_btn_general')}}" class="submit__btn">
    </form>

</div>
@endsection

[+] ..
[-] membership_lounge_payform.blade.php [edit]
[-] membership_lounge_form.blade.php [edit]
[-] membership_lounge_dashboard.blade.php [edit]
[-] immunization_profile_form.blade.php [edit]