ikan Uploader :
Directory : /var/www/html/shardahospital.org/cowin/application/views/
Upload File : |
| Current File : /var/www/html/shardahospital.org/cowin/application/views/my_profile.php |
<div class="container">
<div class="row">
<div class="col col-lg-12">
<div class="login-header">
<!-- <p>Already a Member?</p>
<button type="button" class="btn btn-primary header-btn" onclick="window.location.href = 'login.html';">Login </button>-->
</div>
</div>
</div>
</div>
<div class="container">
<div class="row">
<div class="col-lg-3"></div>
<div class="col-lg-6">
<div class="login-rectangle">
<?php
$record_num = end($this->uri->segment_array());
if($record_num=='addnewprofile') { ?>
<a href="<?=base_url('dashboard')?>" class="backtodash"><i class="fa fa-arrow-left" aria-hidden="true"></i> Back </a>
<?php } ?>
<div class="login-logo">
<img src="<?=base_url('assests/imgs')?>/logo_new.png">
</div>
<form action="" method="POST" enctype="multipart/form-data">
<?php if (validation_errors()) { ?>
<div class="alert alert-danger"><?= validation_errors() ?></div>
<?php } ?>
<div class="login-sec">
<h2>Register for Vaccination</h2>
<p>Please provide the Co-WIN registration details used to register this user.</p>
<div class="radio-btn">
<span>Vaccination </span>
<label><input type="radio" name="vaccination_type" id="vaccination_type" value="1" checked onclick="return showHide('1');" <?php if($_POST['vaccination_type']=='1') { echo 'checked'; }?> >Onsite </label>
<label><input type="radio" name="vaccination_type" id="vaccination_type" value="2" onclick="return showHide('2');" <?php if($_POST['vaccination_type']=='2') { echo 'checked'; }?>>Onspot </label>
</div>
<span style="display:none;" id="corporate_name">
<select name="company_name" id="company_name">
<option value="" >Select Company</option>
<?php foreach($companyArray as $row) { ?>
<option value="<?=$row['title']?>" <?php if($_POST['company_name'] ==$row['title']){ echo 'selected'; }?>><?=$row['title']?></option>
<?php } ?>
</select>
<select name="other_id_proof" id="other_id_proof">
<option value="" >Photo Id Proof</option>
<?php foreach($idproofArray as $row) { ?>
<option value="<?=$row['title']?>" <?php if($_POST['other_id_proof'] ==$row['title']){ echo 'selected'; }?>><?=$row['title']?></option>
<?php } ?>
</select>
</span>
<span id="onsite_name">
<select name="id_proof" id="id_proof">
<!--<option value="" >Photo Id Proof</option>-->
<?php foreach($proofArray as $row) { ?>
<option value="<?=$row['title']?>" <?php if($_POST['id_proof'] ==$row['title']){ echo 'selected'; }?>><?=$row['title']?></option>
<?php } ?>
</select>
</span>
<input type="text" name="full_name" id="full_name" autocomplete=OFF maxlength=245 placeholder="Beneficiary Name (as in ID Proof)" value="<?php echo $_POST['full_name']?>" required>
<small id="website">If not registered on Co-WIN portal please <a href="https://selfregistration.cowin.gov.in/" target="_blank">Register at Co-WIN portal</a></small>
<input type="text" name="aadhar_number" id="aadhar_number" autocomplete=OFF maxlength=12 placeholder="Beneficiary Cowin Ref ID Number" value="<?php echo $_POST['aadhar_number']?>" required>
<input type="email" name="email_id" value="<?php echo $_POST['email_id']?>" id="email_id" autocomplete=OFF maxlength=120 placeholder="Beneficiary Email ID">
<div class="radio-btn">
<span>Date Of Birth(As per ID Proof)</span>
<input type="date" name="dob" value="<?php echo $_POST['dob']?>" id="dob" autocomplete=OFF placeholder="Beneficiary DOB(as in ID Proof)" required>
</div>
<div class="radio-btn">
<span id="cowin_ref">COWIN REF ID Reciept</span>
<input type="file" name="photo_proof" id="photo_proof" placeholder="Upload Photo id Proof">
<small>(Only jpg, jpeg, png and pdf allowed)</small>
</div>
<div class="radio-btn">
<span>Gender</span>
<label><input type="radio" name="gender" id="gender" value="Male" <?php if($_POST['gender'] =='Male' || $_POST['gender'] ==''){ echo 'checked'; }?> >Male </label>
<label><input type="radio" name="gender" id="gender" value="Female" <?php if($_POST['gender'] =='Female'){ echo 'checked'; }?> >Female </label>
<label><input type="radio" name="gender" id="gender" value="Other" <?php if($_POST['gender'] =='Female'){ echo 'checked'; }?>>Other </label>
</div>
<input type="text" name="address" id="address" value="<?php echo $_POST['address']?>" maxlength=245 placeholder="Beneficiary Address" />
<div class="radio-btn">
<span style="color:red;">*All Fileds are mandatory</span>
</div>
<button type="submit" class="btn btn-primary login-btn">Register </button>
</div>
</form>
<div class="login-pin"></div>
</div>
</div>
<div class="col col-lg-3"></div>
</div>
</div>
<script>
function showHide(actype)
{
if(actype=='2') {
$('#corporate_name').show();
$('#onsite_name').hide();
$('#website').hide();
$('#aadhar_number').attr("placeholder", "Beneficiary ID Proof Number.");
$('#address').attr("placeholder", "Full Company Address With Pincode.");
$('#cowin_ref').html("Please upload photo id proof");
} else {
$('#corporate_name').hide();
$('#onsite_name').show();
}
}
<?php if($_POST['vaccination_type']<>'') { ?>
$(window).load(function() {
// executes when complete page is fully loaded, including all frames, objects and images
showHide(<?=$_POST['vaccination_type']?>);
});
<?php } ?>
</script>
</body>
</html>
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