@php
@endphp
@extends('layouts.master')

@section('title', 'Add/Edit Other source of Contact information for any urgent case')

@section('style')
    <style>
    </style>
@endsection

@section('script')
    <script></script>
@endsection

@section('content')

    @include('layouts.header')
    @include('layouts.header-sub')

    <section class="wrapper bg-light">
        <div class="container py-14 py-md-16">
            <div class="row gx-lg-8 gx-xl-12">

                <div class="col-md-12">
                    <h5 class="display-1 mb-3" style="font-size: 30px">@yield('title')</h5>
                    <p class="lead fs-lg pe-lg-15 pe-xxl-12"></p>
                </div>

                <div class="col-lg-12">
                    <div class="blog single">
                        <div class="card">
                            <div class="card-body">

                                <form action="{{ url('/emergencyedit') }}" class="text-start mb-3" method="post"
                                    enctype="multipart/form-data">
                                    @csrf
                                    <input type="text" name="user_emergency_id"
                                        value="{{ $emergency->user_emergency_id ?? '' }}" hidden />
                                    <input type="hidden" name="user_id" value="{{ $id }}">
                                    @if ($errors->any())
                                        <div class="alert alert-danger">
                                            <ul class="mb-0">
                                                @foreach ($errors->all() as $error)
                                                    <li>{{ $error }}</li>
                                                @endforeach
                                            </ul>
                                        </div>
                                    @endif
                                    <div class="row">

                                        {{-- First Name --}}
                                        <div class="col-md-6">
                                            <div class="form-floating mb-4">
                                                <input type="text" class="form-control" name="user_emergency_name"
                                                    value="{{ old('user_emergency_name', $emergency->user_emergency_name ?? '') }}"
                                                    placeholder="First Name" required>
                                                <label>First Name*</label>
                                            </div>
                                        </div>

                                        {{-- Surname --}}
                                        <div class="col-md-6">
                                            <div class="form-floating mb-4">
                                                <input type="text" class="form-control" name="user_emergency_surname"
                                                    value="{{ old('user_emergency_surname', $emergency->user_emergency_surname ?? '') }}"
                                                    placeholder="Surname" required>
                                                <label>Surname*</label>
                                            </div>
                                        </div>

                                        {{-- Relationship --}}
                                        <div class="col-md-6">
                                            <div class="form-floating mb-4">
                                                <input type="text" class="form-control"
                                                    name="user_emergency_relationship"
                                                    value="{{ old('user_emergency_relationship', $emergency->user_emergency_relationship ?? '') }}"
                                                    placeholder="Relationship" required>
                                                <label>Relationship*</label>
                                            </div>
                                        </div>

                                        {{-- Citizen / Passport --}}
                                        <div class="col-md-6">
                                            <div class="form-floating mb-4">
                                                <input type="text" class="form-control" name="user_emergency_citizen_no"
                                                    value="{{ old('user_emergency_citizen_no', $emergency->user_emergency_citizen_no ?? '') }}"
                                                    placeholder="Citizen No. / Passport No." required>
                                                <label>Citizen No./Passport No.*</label>
                                            </div>
                                        </div>

                                        {{-- Residence Address --}}
                                        <div class="col-md-6">
                                            <div class="form-floating mb-4">
                                                <textarea class="form-control" name="user_emergency_res_add" placeholder="Residence Address" style="height:100px"
                                                    required>{{ old('user_emergency_res_add', $emergency->user_emergency_res_add ?? '') }}</textarea>
                                                <label>Residence Address*</label>
                                            </div>
                                        </div>

                                        {{-- Mailing Address --}}
                                        <div class="col-md-6">
                                            <div class="form-floating mb-4">
                                                <textarea class="form-control" name="user_emergency_mail_add" placeholder="Mailing Address" style="height:100px"
                                                    required>{{ old('user_emergency_mail_add', $emergency->user_emergency_mail_add ?? '') }}</textarea>
                                                <label>Mailing Address*</label>
                                            </div>
                                        </div>

                                        {{-- Mobile Phone --}}
                                        <div class="col-md-6">
                                            <div class="form-floating mb-4">
                                                <input type="text" class="form-control"
                                                    name="user_emergency_mobile_phone"
                                                    value="{{ old('user_emergency_mobile_phone', $emergency->user_emergency_mobile_phone ?? '') }}"
                                                    placeholder="Mobile Phone" required>
                                                <label>Mobile Phone No.*</label>
                                            </div>
                                        </div>

                                        {{-- Home Phone --}}
                                        <div class="col-md-6">
                                            <div class="form-floating mb-4">
                                                <input type="text" class="form-control" name="user_emergency_home_phone"
                                                    value="{{ old('user_emergency_home_phone', $emergency->user_emergency_home_phone ?? '') }}"
                                                    placeholder="Home Phone">
                                                <label>Home Phone No.</label>
                                            </div>
                                        </div>

                                        {{-- Email 1 --}}
                                        <div class="col-md-6">
                                            <div class="form-floating mb-4">
                                                <input type="email" class="form-control" name="user_emergency_email_add1"
                                                    value="{{ old('user_emergency_email_add1', $emergency->user_emergency_email_add1 ?? '') }}"
                                                    placeholder="Email 1" required>
                                                <label>E-mail Address (1)*</label>
                                            </div>
                                        </div>

                                        {{-- Email 2 --}}
                                        <div class="col-md-6">
                                            <div class="form-floating mb-4">
                                                <input type="email" class="form-control" name="user_emergency_email_add2"
                                                    value="{{ old('user_emergency_email_add2', $emergency->user_emergency_email_add2 ?? '') }}"
                                                    placeholder="Email 2">
                                                <label>E-mail Address (2)</label>
                                            </div>
                                        </div>


                                    </div>
                                    <br>
                                    <div align="center">
                                        <input class="btn btn-blue rounded-pill" type="submit" name="submit"
                                            value="Submit">
                                        <a class="btn btn-grape rounded-pill"
                                            href="{{ url('/personal_information/' . $id) }}"
                                            title="List">Back</a>
                                    </div>
                                </form>


                            </div>
                        </div>
                    </div>
                </div>
            </div>
        </div>
    </section>

    @include('layouts.footer')

@endsection