@include('_partials_admin.head')
<!-- Page content -->
<div class="page-content">


	<!-- Main content -->
	<div class="content-wrapper">


		<!-- Content area -->
		<div class="content pt-0">

			<!-- Basic responsive configuration -->
			<div class="card col-md-6 mt-5 mx-auto d-block">
				<div class="card-body">
					<form action="/Frontend/Form/tambah" class="form-validate-jquery" method="POST" enctype="multipart/form-data">

						{{ csrf_field() }}
						<div class="col-md-12">
							<fieldset>
								<legend class="font-weight-semibold text-center">APPLICATION FORM<br> UNI-BRIDGE ENGLISH PROGRAM</legend>

								<div class="form-group">
									<p class="font-weight-bold">PERSONAL DETAILS:</p>
								</div>
								
								<div class="form-group">
									<label>Enter your name:<span class="text-danger">*</span></label>
									<input type="text" class="form-control" name="nama_lengkap" placeholder="Full name" required value="{{ old('nama_lengkap') }}">
								</div>

								<div class="form-group">
									<label>Gender:<span class="text-danger">*</span></label>
									<select class="form-control" name="gender" required>
										<option value="" selected="" disabled="">Choose your gender</option>
										<option value="Male">Male</option>
										<option value="Female">Female</option>
									</select>
								</div>

								<div class="form-group">
									<label>Enter your place of birthday:<span class="text-danger">*</span></label>
									<input type="text" class="form-control" name="tempat_lahir" placeholder="Place of birth" value="{{ old('tempat_lahir') }}" required>
								</div>

								<div class="form-group">
									<div class="input-group">
										<span class="input-group-prepend">
											<span class="input-group-text">Enter your birthday:<span class="text-danger">*</span></span>
										</span>
										<input type="text" class="form-control pickadate-accessibility picker__input" name="tanggal_lahir" value="{{ old('tanggal_lahir') }}" placeholder="Date of birth" required>
									</div>
								</div>

								<div class="form-group">
									<label>Enter your home phone number:<span class="text-danger">*</span></label>
									<input type="text" class="form-control" name="telepon_rumah" placeholder="Home phone number" value="{{ old('telepon_rumah') }}" required>
								</div>

								<div class="form-group">
									<label>Enter your mobile number:<span class="text-danger">*</span></label>
									<input type="text" class="form-control" name="nomor_telepon" placeholder="Mobile number" value="{{ old('nomor_telepon') }}" required>
								</div>

								<div class="form-group">
									<label>Enter your email address:<span class="text-danger">*</span></label>
									<input type="email" class="form-control" name="email" placeholder="Email address" value="{{ old('email') }}" required>
								</div>

								<div class="form-group">
									<label>Home address:<span class="text-danger">*</span></label>
									<textarea class="form-control" name="alamat" required>{{ old('alamat') }}</textarea>
								</div>

								<div class="accordion" id="accordionExample">
									<div class="card">
										<div class="card-header" id="heading3">
											<h2 class="mb-0">
												<button class="btn btn-link collapsed text-left text-dark" type="button" data-toggle="collapse" data-target="#collapse3" aria-expanded="false" aria-controls="collapse3">
													ACADEMIC BACKGROUND FOR STUDENT ONLY:
												</button>
											</h2>
										</div>
										<div id="collapse3" class="collapse" aria-labelledby="heading3" data-parent="#accordionExample">
											<div class="card-body">

												<div class="form-group">
													<label>Name of previous school:<span class="text-danger">*</span></label>
													<input type="text" class="form-control" name="educational" placeholder="Name of previous school" value="{{ old('educational') }}">
												</div>

												<div class="form-group">
													<label>Address of previous school:<span class="text-danger">*</span></label>
													<input type="text" class="form-control" name="address_school" placeholder="Address of previous school" value="{{ old('address_school') }}">
												</div>

												<div class="form-group">
													<label>Curriculum used:<span class="text-danger">*</span></label>
													<input type="text" class="form-control" name="curriculum" placeholder="Curriculum used" value="{{ old('curriculum') }}">
												</div>

												<div class="form-group">
													<label>What is your current qualification:<span class="text-danger">*</span></label>
													<textarea class="form-control" name="qualification">{{ old('qualification') }}</textarea>
												</div>

												<div class="form-group">
													<label class="font-weight-bold">PARENTS/ GUARDIAN DETAILS FOR STUDENTS ONLY:</label>
												</div>

												<span class="font-weight-semibold">Father</span>
												<hr>
												<div class="form-group ml-4">
													<label>Enter name:<span class="text-danger">*</span></label>
													<input type="text" class="form-control" name="nama_ayah" placeholder="Full name" value="{{ old('nama_ayah') }}">
												</div>
												<div class="form-group ml-4">
													<label>Enter mobile number:<span class="text-danger">*</span></label>
													<input type="text" class="form-control" name="nomor_ayah" placeholder="Mobile number" value="{{ old('nomor_ayah') }}">
												</div>
												<div class="form-group ml-4">
													<label>Enter email address:<span class="text-danger">*</span></label>
													<input type="email" class="form-control" name="email_ayah" placeholder="Email address" value="{{ old('email_ayah') }}">
												</div>

												<span class="font-weight-semibold">Mother</span>
												<hr>
												<div class="form-group ml-4">
													<label>Enter name:<span class="text-danger">*</span></label>
													<input type="text" class="form-control" name="nama_ibu" placeholder="Full name" value="{{ old('nama_ibu') }}">
												</div>
												<div class="form-group ml-4">
													<label>Enter mobile number:<span class="text-danger">*</span></label>
													<input type="text" class="form-control" name="nomor_ibu" placeholder="Mobile number" value="{{ old('nomor_ibu') }}">
												</div>
												<div class="form-group ml-4">
													<label>Enter email address:<span class="text-danger">*</span></label>
													<input type="text" class="form-control" name="email_ibu" placeholder="Email address" value="{{ old('email_ibu') }}">
												</div>

												<span class="font-weight-semibold">Guardian (if opted):</span>
												<hr>
												<div class="form-group ml-4">
													<label>Enter name:</label>
													<input type="text" class="form-control" name="nama_wali" placeholder="Full name" value="{{ old('nama_wali') }}">
												</div>
												<div class="form-group ml-4">
													<label>Enter mobile number:</label>
													<input type="text" class="form-control" name="nomor_wali" placeholder="Mobile number" value="{{ old('nomor_wali') }}">
												</div>
												<div class="form-group ml-4">
													<label>Enter email address:</label>
													<input type="email" class="form-control" name="email_wali" placeholder="Email address" value="{{ old('email_wali') }}">
												</div>

												<div class="form-group">
													<label>Address (if different from main address):</label>
													<textarea class="form-control" name="alamat_2">{{ old('alamat_2') }}</textarea>
												</div>
											</div>
										</div>
									</div>
									<div class="card">
										<div class="card-header" id="heading4">
											<h2 class="mb-0">
												<button class="btn btn-link collapsed text-left text-dark" type="button" data-toggle="collapse" data-target="#collapse4" aria-expanded="false" aria-controls="collapse4">
													PERSONAL BACKGROUND FOR ADULT ONLY:
												</button>
											</h2>
										</div>
										<div id="collapse4" class="collapse" aria-labelledby="heading4" data-parent="#accordionExample">
											<div class="card-body">

												<div class="form-group">
													<label>Latest educational background:<span class="text-danger">*</span></label>
													<input type="text" class="form-control" name="latest_educational_background" placeholder="Latest educational background" value="{{ old('latest_educational_background') }}">
												</div>

												<div class="form-group">
													<label>Occupation:<span class="text-danger">*</span></label>
													<input type="text" class="form-control" name="occupation" placeholder="Occupation" value="{{ old('occupation') }}">
												</div>

												<div class="form-group">
													<label>Company name:</label>
													<input type="text" class="form-control" name="company_name" placeholder="Company name" value="{{ old('company_name') }}">
												</div>

												<div class="form-group">
													<label>What is your current qualification:</label>
													<textarea class="form-control" name="qualification_2" >{{ old('qualification_2') }}</textarea>
												</div>
											</div>
										</div>
									</div>
								</div>

								<div class="form-group">
									<table class="table table-bordered">
										<tr>
											<th colspan="5">UNI-BRIDGE ENGLISH PROGRAM<span class="text-danger">*</span></th>
										</tr>
										<tr>
											<td colspan="5">
												<select class="form-control" name="program" id="program" required>
													<option value="" disabled="" selected="">CHOOSE PROGRAM</option>
													<optgroup label="EARLY LEARNERS">
														<option value="Pre-Starters">Pre-Starters</option>
														<option value="Starters">Starters</option>
														<option value="Movers">Movers</option>
														<option value="Flyers">Flyers</option>
													</optgroup>
													<optgroup label="INTERMEDIATE">
														<option value="KET (Key English Test)">KET (Key English Test)</option>
														<option value="PET (Preliminary English Test)">PET (Preliminary English Test)</option>
													</optgroup>
													<optgroup label="OTHER PROGRAMS">
														<option value="IELTS 20 HOURS MODULE">IELTS 20 HOURS MODULE</option>
														<option value="IELTS 40 HOURS MODULE">IELTS 40 HOURS MODULE</option>
														<option value="CERTIFICATE IV IN TESOL">CERTIFICATE IV IN TESOL</option>
														<option value="Conversation Classes">Conversation Classes</option>
													</optgroup>
												</select>
											</td>
										</tr>

									</table>
								</div>

								<div id="attachment">
									
								</div>
							

								

							</fieldset>
							<p class="text-right font-italic"><span class="text-danger">*</span>required</p>
						</div>

						<ul class="mb-3 mt-3">
							<li>I hereby acknowledge that all of the above information provided to Uni-bridge, is true to the best of my knowledge.</li>
							<li>I further allow Uni-bridge to carry further assessment on the above information should it prove to be necessary.</li>
						</ul>

						28 Jul 2026

						<div class="text-right">
							<button type="submit" class="btn btn-primary">Submit form <i class="icon-paperplane ml-2"></i></button>
						</div>
					</form>
				</div>
			</div>
			<!-- /basic responsive configuration -->

		</div>
		<!-- /content area -->
	</div>
	<!-- /main content -->

</div>
<!-- /page content -->
<script type="text/javascript">
	$(document).ready(function(){
		$('#program').change(function(){
			select_country();
		});
	});

	function select_country(){
		var programs = $('#program').val();
		if (programs == 'CERTIFICATE IV IN TESOL') {
			$('#attachment').html('<div class="form-group"><label class="font-weight-bold">For Application to Certificate IV in TESOL, please select your current educational background:</label></div><div class="accordion" id="accordionExample"><div class="card"><div class="card-header" id="headingTwo"><h2 class="mb-0"><button class="btn btn-link collapsed text-left text-dark" type="button" data-toggle="collapse" data-target="#collapseTwo" aria-expanded="false" aria-controls="collapseTwo">Complete Bachelor Degree (Strata 1) on English Language Teaching or English Literature</button></h2></div><div id="collapseTwo" class="collapse" aria-labelledby="headingTwo" data-parent="#accordionExample"><div class="card-body"><div class="form-group"><label>Certificate completion of Sarjana Strata 1 (Bachelor Degree):<span class="text-danger">*</span></label><input type="file" class="form-control @error("document")is-invalid @enderror" name="document"><p class="font-italic text-info">(Max: 1MB, Type: JPG/PDF)</p>@error("document")<p class="text-danger">{{ $message }}</p>@enderror</div><div class="form-group"><label>Academic transcript of Sarjana Strata 1 (Bachelor Degree):<span class="text-danger">*</span></label><input type="file"  class="form-control @error("document2")is-invalid @enderror" name="document2"><p class="font-italic text-info">(Max: 1MB, Type: JPG/PDF)</p>@error("document")<p class="text-danger">{{ $message }}</p>@enderror</div><div class="form-group"><label>Copy of passport (personal details page only) if available and ID Card:</label><input type="file"  class="form-control @error("document3")is-invalid @enderror" name="document3"><p class="font-italic text-info">(Max: 1MB, Type: JPG/PDF)</p>@error("document3")<p class="text-danger">{{ $message }}</p>@enderror</div></div></div></div><div class="card"><div class="card-header" id="headingThree"><h2 class="mb-0"><button class="btn btn-link collapsed text-left text-dark" type="button" data-toggle="collapse" data-target="#collapseThree" aria-expanded="false" aria-controls="collapseThree">Complete Semester IV of Bachelor Degree (Strata 1) on English Teaching or English Literature </button></h2></div><div id="collapseThree" class="collapse" aria-labelledby="headingThree" data-parent="#accordionExample"><div class="card-body"><div class="form-group"><label>Academic transcript of Semester 1 - 4:<span class="text-danger">*</span></label><input type="file" class="form-control @error("document4")is-invalid @enderror" name="document4"><p class="font-italic text-info">(Max: 1MB, Type: JPG/PDF)</p>@error("document4")<p class="text-danger">{{ $message }}</p>@enderror</div><div class="form-group"><label>Copy of passport (personal details page only) if available and ID Card:</label><input type="file"  class="form-control @error("document5")is-invalid @enderror" name="document5"><p class="font-italic text-info">(Max: 1MB, Type: JPG/PDF)</p>@error("document5")<p class="text-danger">{{ $message }}</p>@enderror</div></div></div></div></div>');
		}else{
			$('#attachment').html('');
		}
	}
</script>

@if ($message = Session::get('sukses'))
<script type="text/javascript">
	$(document).ready(function () {
		new Noty(
			{text: 'Data telah disimpan.', type: 'success'}
			).show();
	});
</script>
@elseif (Session::get('gagal'))
<script type="text/javascript">
	$(document).ready(function () {
		new Noty(
			{text: 'Data gagal disimpan.', type: 'error'}
			).show();
	});
</script>
@elseif (Session::get('gagal_foreign'))
<script type="text/javascript">
	$(document).ready(function () {
		new Noty(
			{text: 'Data gagal dihapus, karena masih terhubung dengan data yang lain.', type: 'error'}
			).show();
	});
</script>
@endif

</body>
</html>