@extends('layouts.Layout')

@section('content')
<div class="col-md-12">
    <div class="card">
        <div class="header">
	        <h3>Form Pendaftaran Online</h3>
	        <p class="category"></p>
	    </div>
	    <div class="content">
	    <form action="#" id="frmsave" method="post">
	    {{ csrf_field() }}
	    	<center><h4>Data Pribadi</h4></center>
	    	<div class="row">
		    	<div class="col-lg-6">
	                <div class="form-group @if($errors->has('nama')) has-error @endif">
	                    <input type="text" class="form-control border-input" value="{{old('nama')}}" name="nama" placeholder="Nama Lengkap">
	                    <span id="helpBlock2" class="help-block" >{{$errors->first('nama')}}</span>
	                </div>
	            </div>
            
		    	<div class="col-lg-3">
	                <div class="form-group @if($errors->has('jeniskelamin')) has-error @endif">
	                    <select class="form-control border-input" value="{{old('jeniskelamin')}}" name="jeniskelamin">
	                    <option class="0" disabled="true"  selected="true">---Jenis Kelamin---</option>
	                    <option>Perempuan</option>
	                    <option>Laki-laki</option>
	                    </select>
	                </div>
	            </div>
	            <div class="col-lg-3">
	                <div class="form-group @if($errors->has('agama')) has-error @endif">
	                	<select class="form-control border-input" value="{{old('agama')}}" name="agama">
	                    <option class="0" disabled="true"  selected="true">---Pilih Agama---</option>
	                    <option>Kristen Protestan</option>
	                    <option>Kristen Katolik</option>
	                    <option>Islam</option>
	                    <option>Hindu</option>
	                    <option>Buddha</option>
	                    <option>Konghuchu</option>
	                    </select>
	                    <span id="helpBlock2" class="help-block">{{$errors->first('agama')}}</span>
	                </div>
	            </div>
	    	</div>
	    	<div class="row">   
		    	<div class="col-lg-2">
	                <div class="form-group @if($errors->has('tempatlahir')) has-error @endif">
	                    <input type="text" class="form-control border-input" value="{{old('tempatlahir')}}" name="tempatlahir" placeholder="Tempat lahir">
	                    <span id="helpBlock2" class="help-block">{{$errors->first('tempatlahir')}}</span>
	                </div>
	            </div>

		    	<div class="col-lg-2">
	                <div class="form-group @if($errors->has('tanggallahir')) has-error @endif">
	                    <input type="date" class="form-control border-input" value="{{old('tanggallahir')}}" name="tanggallahir" placeholder="Tanggal lahir">
	                    <span id="helpBlock2" class="help-block">{{$errors->first('tanggallahir')}}</span>
	                </div>
	            </div>
	            <div class="col-lg-3">
	                <div class="form-group @if($errors->has('kebutuhan_khusus')) has-error @endif">
	                    <select class="form-control border-input"  value="{{old('kebutuhan_khusus')}}" name="kebutuhan_khusus">
			                    <option class="0" disabled="true"  selected="true">Berkebutuhan khusus ?</option>
			                    <option>Tidak</option>
			                    <option>Netra(A)</option>
			                    <option>Rungu</option>
			                    <option>Grahita Ringan</option>
			                    <option>Grahita Sedang</option>
			                    <option>Daksa Ringan</option>
			                    <option>Daksa Sedang</option>
			                    <option>Laras</option>
			                    <option>Wicara</option>
			                    <option>Hiper Aktif</option>
			                    <option>Cerdas Istimewa</option>
			                    <option>Bakat Istimewa</option>
			                    <option>Kesulitan Belajar</option>
			                    <option>Narkoba</option>
			                    <option>Indigo</option>
			                    <option>Autis</option>
			                    <option>Down Sindrome</option>
			                    <option>Lainnya</option>
		                    </select>
	                    <span id="helpBlock2" class="help-block">{{$errors->first('kebutuhan_khusus')}}</span>
	                </div>
	            </div>
	            <div class="col-lg-3">
	                <div class="form-group @if($errors->has('alamat')) has-error @endif">
	                    <input type="text" class="form-control border-input" value="{{old('alamat')}}" name="alamat" placeholder="Alamat Lengkap">
	                    <span id="helpBlock2" class="help-block">{{$errors->first('alamat')}}</span>
	                </div>
	            </div>
	            <div class="col-lg-2">
	                <div class="form-group @if($errors->has('no_hp')) has-error @endif">
	                    <input type="text" class="form-control border-input" value="{{old('no_hp')}}" name="no_hp" placeholder="Nomor Telepon">
	                    <span id="helpBlock2" class="help-block">{{$errors->first('no_hp')}}</span>
	                </div>
	            </div>
	        </div>
            <center><h4>Data Periodik</h4></center>
            <div class="row">
            	<div class="col-lg-2">
	                <div class="form-group @if($errors->has('tinggi_badan')) has-error @endif">
	                    <input type="text" placeholder="Tinggi badan (CM)" class="form-control border-input" value="{{old('tinggi_badan')}}" name="tinggi_badan">
	                    <span id="helpBlock2" class="help-block">{{$errors->first('tinggi_badan')}}</span>
	                </div>
	            </div>
		    	<div class="col-lg-2">
	                <div class="form-group @if($errors->has('berat_badan')) has-error @endif">
	                    <input type="text" placeholder="Berat badan (KG)" class="form-control border-input" value="{{old('berat_badan')}}" name="berat_badan">
	                    <span id="helpBlock2" class="help-block">{{$errors->first('berat_badan')}}</span>
	                </div>
	            </div>
		    	<div class="col-lg-3">
	                <div class="form-group @if($errors->has('jarak_kesekolah')) has-error @endif">
	                    <input type="text" placeholder="Jarak rumah ke sekolah (M)" class="form-control border-input" value="{{old('jarak_kesekolah')}}" name="jarak_kesekolah">
	                    <span id="helpBlock2" class="help-block">{{$errors->first('jarak_kesekolah')}}</span>
	                </div>
	            </div>

		    	<div class="col-lg-3">
	                <div class="form-group @if($errors->has('waktu_tempuh')) has-error @endif">
	                    <input type="text" placeholder="Waktu tempuh (Menit)" class="form-control border-input" value="{{old('waktu_tempuh')}}" name="waktu_tempuh">
	                    <span id="helpBlock2" class="help-block">{{$errors->first('waktu_tempuh')}}</span>
	                </div>
	            </div>

		    	<div class="col-md-2">
	                <div class="form-group @if($errors->has('jumlah_saudara')) has-error @endif">
	                    <input type="text" placeholder="Jumlah Saudara" class="form-control border-input" value="{{old('jumlah_saudara')}}" name="jumlah_saudara">
	                    <span id="helpBlock2" class="help-block">{{$errors->first('jumlah_saudara')}}</span>
	                </div>
	            </div>
	           </div>


	           <center><h4>Data Asal Sekolah</h4></center>
	           	<div class="row">
			    	<div class="col-lg-4">
		                <div class="form-group @if($errors->has('nama_sekolah')) has-error @endif">
		                    <input type="text" placeholder="Nama SMP" class="form-control border-input" value="{{old('nama_sekolah')}}" name="nama_sekolah">
		                    <span id="helpBlock2" class="help-block">{{$errors->first('nama_sekolah')}}</span>
		                </div>
		            </div>

			    	<div class="col-lg-4">
		                <div class="form-group @if($errors->has('alamat_sekolah')) has-error @endif">
		                    <input type="text" placeholder="Alama lengkap sekolah" class="form-control border-input" value="{{old('alamat_sekolah')}}" name="alamat_sekolah">
		                    <span id="helpBlock2" class="help-block">{{$errors->first('alamat_sekolah')}}</span>
		                </div>
		            </div>
		            <div class="col-lg-4">
			                <div class="form-group @if($errors->has('nik')) has-error @endif">
			                    <input type="text" placeholder="NIK" class="form-control border-input" value="{{old('nik')}}" name="nik">
			                    <span id="helpBlock2" class="help-block">{{$errors->first('nik')}}</span>
			                </div>
			        </div>
	            </div>
	            <div class="row">	
		            <div class="col-lg-3">
		                <div class="form-group @if($errors->has('no_ujiannasional')) has-error @endif">
		                    <input type="text" placeholder="Nomor Ujian Nasional" class="form-control border-input" value="{{old('no_ujiannasional')}}" name="no_ujiannasional">
		                    <span id="helpBlock2" class="help-block">{{$errors->first('no_ujiannasional')}}</span>
		                </div>
		            </div>
		            <div class="col-lg-3">
		                <div class="form-group @if($errors->has('nisn')) has-error @endif">
		                    <input type="text" placeholder="Nomor Induk Siswa Nasional" class="form-control border-input" value="{{old('nisn')}}" name="nisn">
		                    <span id="helpBlock2" class="help-block">{{$errors->first('nisn')}}</span>
		                </div>
		            </div>
			    	<div class="col-lg-3">
		                <div class="form-group @if($errors->has('no_ijazah')) has-error @endif">
		                    <input type="text" placeholder="Nomor Ijazah SMP" class="form-control border-input" value="{{old('no_ijazah')}}" name="no_ijazah">
		                    <span id="helpBlock2" class="help-block">{{$errors->first('no_ijazah')}}</span>
		                </div>
		            </div>
			    	<div class="col-lg-3">
		                <div class="form-group @if($errors->has('no_skhun')) has-error @endif">
		                    <input type="text" placeholder="Nomor SKHUN" class="form-control border-input" value="{{old('no_skhun')}}" name="no_skhun">
		                    <span id="helpBlock2" class="help-block">{{$errors->first('no_skhun')}}</span>
		                </div>
		            </div>
		    	
            	</div>
            	<center><h4>Data OrangTua</h4></center>
            	<div class="row">
			    	<div class="col-lg-3">
		                <div class="form-group @if($errors->has('nama_ayah')) has-error @endif">
		                    <input type="text" class="form-control border-input" value="{{old('nama_ayah')}}" name="nama_ayah" placeholder="nama ayah">
		                    <span id="helpBlock2" class="help-block">{{$errors->first('nama_ayah')}}</span>
		                </div>
		            </div>
		            <div class="col-lg-3">
	                	<div class="form-group @if($errors->has('tanggal_lahir_ayah')) has-error @endif">
		                    <input type="date" class="form-control border-input" value="{{old('tanggal_lahir_ayah')}}" name="tanggal_lahir_ayah" placeholder="Tanggal lahir ayah">
		                    <span id="helpBlock2" class="help-block">{{$errors->first('tanggal_lahir_ayah')}}</span>
	                	</div>
	            	</div>
	            	<div class="col-lg-3">
		                <div class="form-group @if($errors->has('kebutuhan_khus_ayah')) has-error @endif">
		                	<select class="form-control border-input"  value="{{old('kebutuhan_khus_ayah')}}" name="kebutuhan_khus_ayah">
			                    <option class="0" disabled="true"  selected="true">Berkebutuhan khusus ?</option>
			                    <option>Tidak</option>
			                    <option>Netra(A)</option>
			                    <option>Rungu</option>
			                    <option>Grahita Ringan</option>
			                    <option>Grahita Sedang</option>
			                    <option>Daksa Ringan</option>
			                    <option>Daksa Sedang</option>
			                    <option>Laras</option>
			                    <option>Wicara</option>
			                    <option>Hiper Aktif</option>
			                    <option>Cerdas Istimewa</option>
			                    <option>Bakat Istimewa</option>
			                    <option>Kesulitan Belajar</option>
			                    <option>Narkoba</option>
			                    <option>Indigo</option>
			                    <option>Autis</option>
			                    <option>Down Sindrome</option>
			                    <option>Lainnya</option>
		                    </select>
		                    <span id="helpBlock2" class="help-block">{{$errors->first('kebutuhan_khus_ayah')}}</span>
		                </div>
		            </div>
		            <div class="col-sm-3">
		                <div class="form-group @if($errors->has('pendidikan_ayah')) has-error @endif">
		                <select class="form-control border-input"  value="{{old('pendidikan_ayah')}}" name="pendidikan_ayah">
		                	<option class="0" disabled="true"  selected="true">Pendidikan Terakhir Ayah</option>
		                	<option> TK </option>
		                	<option> SD </option>
		                	<option> SMP </option>
		                	<option> SMA </option>
		                	<option> Diploma </option>
		                	<option> Sarjana</option>
		                	<option> Lainnya</option>
		                </select>
		                    <span id="helpBlock2" class="help-block">{{$errors->first('pendidikan_ayah')}}</span>
		                </div>
		            </div>
		        </div>
            	<div class="row">
            		<div class="col-lg-3">
		                <div class="form-group @if($errors->has('pekerjaan_ayah')) has-error @endif">
		                <select class="form-control border-input"  value="{{old('pekerjaan_ayah')}}" name="pekerjaan_ayah">
		                	<option class="0" disabled="true"  selected="true">Pekerjaan Ayah</option>
		                	<option> Wiraswasta</option>
		                	<option> PNS</option>
		                	<option> Polisi</option>
		                	<option> Petani</option>
		                	<option> Nelayan</option>
		                	<option> Buruh</option>
		                	<option> Lainnya</option>
		                </select>
		                    <span id="helpBlock2" class="help-block">{{$errors->first('pekerjaan_ayah')}}</span>
		                </div>
		            </div>
		            
		            <div class="col-lg-3">
	                	<div class="form-group @if($errors->has('penghasilan_bulanan_ayah')) has-error @endif">
		                    <input type="text" class="form-control border-input" value="{{old('penghasilan_bulanan_ayah')}}" name="penghasilan_bulanan_ayah" placeholder="Penghasilan Ayah Per Bulan">
		                    <span id="helpBlock2" class="help-block">{{$errors->first('penghasilan_bulanan_ayah')}}</span>
	                	</div>
	            	</div>
            	</div>
            	<div class="row">
			    	<div class="col-lg-3">
		                <div class="form-group @if($errors->has('nama_ibu')) has-error @endif">
		                    <input type="text" class="form-control border-input" value="{{old('nama_ibu')}}" name="nama_ibu" placeholder="nama ibu">
		                    <span id="helpBlock2" class="help-block">{{$errors->first('nama_ibu')}}</span>
		                </div>
		            </div>
		            <div class="col-lg-3">
	                	<div class="form-group @if($errors->has('tanggal_lahir_ibu')) has-error @endif">
		                    <input type="date" class="form-control border-input" value="{{old('tanggal_lahir_ibu')}}" name="tanggal_lahir_ibu" placeholder="Tanggal lahir ibu">
		                    <span id="helpBlock2" class="help-block">{{$errors->first('tanggal_lahir_ibu')}}</span>
	                	</div>
	            	</div>
	            	<div class="col-lg-3">
		                <div class="form-group @if($errors->has('kebutuhan_khus_ibu')) has-error @endif">
		                	<select class="form-control border-input"  value="{{old('kebutuhan_khus_ibu')}}" name="kebutuhan_khus_ibu">
			                    <option class="0" disabled="true"  selected="true">Berkebutuhan khusus ?</option>
			                    <option>Tidak</option>
			                    <option>Netra(A)</option>
			                    <option>Rungu</option>
			                    <option>Grahita Ringan</option>
			                    <option>Grahita Sedang</option>
			                    <option>Daksa Ringan</option>
			                    <option>Daksa Sedang</option>
			                    <option>Laras</option>
			                    <option>Wicara</option>
			                    <option>Hiper Aktif</option>
			                    <option>Cerdas Istimewa</option>
			                    <option>Bakat Istimewa</option>
			                    <option>Kesulitan Belajar</option>
			                    <option>Narkoba</option>
			                    <option>Indigo</option>
			                    <option>Autis</option>
			                    <option>Down Sindrome</option>
			                    <option>Lainnya</option>
		                    </select>
		                    <span id="helpBlock2" class="help-block">{{$errors->first('kebutuhan_khus_ibu')}}</span>
		                </div>
		            </div>
		            <div class="col-sm-3">
		                <div class="form-group @if($errors->has('pendidikan_ibu')) has-error @endif">
		                <select class="form-control border-input"  value="{{old('pendidikan_ibu')}}" name="pendidikan_ibu">
		                	<option class="0" disabled="true"  selected="true">Pendidikan Terakhir ibu</option>
		                	<option> TK </option>
		                	<option> SD </option>
		                	<option> SMP </option>
		                	<option> SMA </option>
		                	<option> Diploma </option>
		                	<option> Sarjana</option>
		                	<option> Lainnya</option>
		                </select>
		                    <span id="helpBlock2" class="help-block">{{$errors->first('pendidikan_ibu')}}</span>
		                </div>
		            </div>
		        </div>
            	<div class="row">
            		<div class="col-lg-3">
		                <div class="form-group @if($errors->has('pekerjaan_ibu')) has-error @endif">
		                <select class="form-control border-input"  value="{{old('pekerjaan_ibu')}}" name="pekerjaan_ibu">
		                	<option class="0" disabled="true"  selected="true">Pekerjaan ibu</option>
		                	<option> Wiraswasta</option>
		                	<option> PNS</option>
		                	<option> Polisi</option>
		                	<option> Petani</option>
		                	<option> Nelayan</option>
		                	<option> Buruh</option>
		                	<option> Lainnya</option>
		                </select>
		                    <span id="helpBlock2" class="help-block">{{$errors->first('pekerjaan_ibu')}}</span>
		                </div>
		            </div>
		            
		            <div class="col-lg-3">
	                	<div class="form-group @if($errors->has('penghasilan_bulanan_ibu')) has-error @endif">
		                    <input type="text" class="form-control border-input" value="{{old('penghasilan_bulanan_ibu')}}" name="penghasilan_bulanan_ibu" placeholder="Penghasilan ibu Per Bulan">
		                    <span id="helpBlock2" class="help-block">{{$errors->first('penghasilan_bulanan_ibu')}}</span>
	                	</div>
	            	</div>
            	</div>
            	<div class="row">
			    	<div class="col-lg-3">
		                <div class="form-group @if($errors->has('nama_wali')) has-error @endif">
		                    <input type="text" class="form-control border-input" value="{{old('nama_wali')}}" name="nama_wali" placeholder="nama wali">
		                    <span id="helpBlock2" class="help-block">{{$errors->first('nama_wali')}}</span>
		                </div>
		            </div>
		            <div class="col-lg-3">
	                	<div class="form-group @if($errors->has('tanggal_lahir_wali')) has-error @endif">
		                    <input type="date" class="form-control border-input" value="{{old('tanggal_lahir_wali')}}" name="tanggal_lahir_wali" placeholder="Tanggal lahir wali">
		                    <span id="helpBlock2" class="help-block">{{$errors->first('tanggal_lahir_wali')}}</span>
	                	</div>
	            	</div>
	            	<div class="col-lg-3">
		                <div class="form-group @if($errors->has('kebutuhan_khus_wali')) has-error @endif">
		                	<select class="form-control border-input"  value="{{old('kebutuhan_khus_wali')}}" name="kebutuhan_khus_wali">
			                    <option class="0" disabled="true"  selected="true">Berkebutuhan khusus ?</option>
			                    <option>Tidak</option>
			                    <option>Netra(A)</option>
			                    <option>Rungu</option>
			                    <option>Grahita Ringan</option>
			                    <option>Grahita Sedang</option>
			                    <option>Daksa Ringan</option>
			                    <option>Daksa Sedang</option>
			                    <option>Laras</option>
			                    <option>Wicara</option>
			                    <option>Hiper Aktif</option>
			                    <option>Cerdas Istimewa</option>
			                    <option>Bakat Istimewa</option>
			                    <option>Kesulitan Belajar</option>
			                    <option>Narkoba</option>
			                    <option>Indigo</option>
			                    <option>Autis</option>
			                    <option>Down Sindrome</option>
			                    <option>Lainnya</option>
		                    </select>
		                    <span id="helpBlock2" class="help-block">{{$errors->first('kebutuhan_khus_wali')}}</span>
		                </div>
		            </div>
		            <div class="col-sm-3">
		                <div class="form-group @if($errors->has('pendidikan_wali')) has-error @endif">
		                <select class="form-control border-input"  value="{{old('pendidikan_wali')}}" name="pendidikan_wali">
		                	<option class="0" disabled="true"  selected="true">Pendidikan Terakhir wali</option>
		                	<option> TK </option>
		                	<option> SD </option>
		                	<option> SMP </option>
		                	<option> SMA </option>
		                	<option> Diploma </option>
		                	<option> Sarjana</option>
		                	<option> Lainnya</option>
		                </select>
		                    <span id="helpBlock2" class="help-block">{{$errors->first('pendidikan_wali')}}</span>
		                </div>
		            </div>
		        </div>
            	<div class="row">
            		<div class="col-lg-3">
		                <div class="form-group @if($errors->has('pekerjaan_wali')) has-error @endif">
		                <select class="form-control border-input"  value="{{old('pekerjaan_wali')}}" name="pekerjaan_wali">
		                	<option class="0" disabled="true"  selected="true">Pekerjaan wali</option>
		                	<option> Wiraswasta</option>
		                	<option> PNS</option>
		                	<option> Polisi</option>
		                	<option> Petani</option>
		                	<option> Nelayan</option>
		                	<option> Buruh</option>
		                	<option> Lainnya</option>
		                </select>
		                    <span id="helpBlock2" class="help-block">{{$errors->first('pekerjaan_wali')}}</span>
		                </div>
		            </div>
		            
		            <div class="col-lg-3">
	                	<div class="form-group @if($errors->has('penghasilan_bulanan_wali')) has-error @endif">
		                    <input type="text" class="form-control border-input" value="{{old('penghasilan_bulanan_wali')}}" name="penghasilan_bulanan_wali" placeholder="Penghasilan wali Per Bulan">
		                    <span id="helpBlock2" class="help-block">{{$errors->first('penghasilan_bulanan_wali')}}</span>
	                	</div>
	            	</div>
            	</div>
            	<center><h4>Data Prestasi</h4></center>
            	<div class="row">
            	<div class="col-lg-12 col-sm-12">
            		<table class="table table-bordered">
            			<thead>
            				<th>Jenis Prestasi</th>
            				<th>Nama Prestasi</th>
            				<th>Tahun</th>
            				<th>Penyelenggara</th>
            				<th style="text-align: center;"><a href="#" class="addRow"><i class="glyphicon glyphicon-plus"></i></a></th>
            			</thead>
            			<tbody>
            				<tr>
            					<td><input type="text" name="jenis_prestasi[]" class="form-control jenis_prestasi" placeholder="Jenis Prestasi"></td>
            					<td><input type="text" name="nama_prestasi[]" class="form-control nama_prestasi" placeholder="Nama Prestasi"></td>
            					<td><input type="text" name="tahun_prestasi[]" class="form-control tahun_prestasi" placeholder="Tahun Prestasi"></td>
            					<td><input type="text" name="penyelenggara[]" class="form-control penyelenggara" placeholder="Penyelenggara"></td>
            					<td><a href="#" class="btn btn-danger remove"><i class="glyphicon glyphicon-remove"></i></a></td>
            				</tr>
            			</tbody>
            		</table>
            	</div>
            	</div>
            </form>
		</div>
	</div>
</div>
@endsection