@extends('layouts.frontend')

@section('title', '| FREE END-OF-LIFE PLAN')
@section('css')
<link rel="stylesheet" href="//code.jquery.com/ui/1.13.2/themes/base/jquery-ui.css">
@endsection
@section('content')
@include('frontend.forms.End-Of-Life-Plan.stepIndicator')
 <!-- start -->
<div class="container">
    <form action="{{route('EndoflifePlanFormStore')}}" method="POST" id="signUpForm">
      @csrf
      <input type="hidden" id="stepInput" name="step" value="3-2-1">
      <div class="card">
         <div class="card-body">
            <!-- step 1 -->
            <div class="step" style="display: block">
               <div class="row">
                  <div class="col-md-8">
                     <div class="card-title">Your Death Notice</div>
  
                        @php
                        $death_notice = json_decode($endoflifePlanForm->death_notice, true);
                        @endphp
                        <div class="form-group mb-3">
                           <label for="name">Date of Birth:</label>
                           <input type="text" value="{{ old('date_of_birth', $death_notice['date_of_birth'] ?? '') }}"  class="form-control modified-input" name="date_of_birth" id="date_of_birth" placeholder="mm-dd-yy" >
                           <small id="nameHelp" class="form-text text-muted">e.g. The Hanover Gazette, www.legacy.com</small>
                        </div>
                        <div class="form-group mb-3">
                           <label for="name">Birthplace:</label>
                           <input value="{{ old('birthplace', $death_notice['birthplace'] ?? '') }}" type="text" class="form-control modified-input" name="birthplace" aria-describedby="nameHelp" placeholder="Birthplace">
                           <small id="nameHelp" class="form-text text-muted">e.g. Hartford, Connecticut</small>
                        </div>
                     </div>
                     <div class="card-sub-title">Do you want your death notice to list your surviving family members?</div>
                     <div class="custom-button-yn">
                        <input id="family_members-y" name="family_members" value="yes" type="radio" {{ !isset($death_notice['include_surviving_family']) || $death_notice['include_surviving_family']  == 'yes' ? 'checked' : '' }}>
                        <label for="family_members-y">Yes</label>
                        <input id="family_members-n" name="family_members" value="no" type="radio" {{ isset($death_notice['include_surviving_family']) && $death_notice['include_surviving_family']  == 'no' ? 'checked' : '' }}>
                        <label for="family_members-n">No</label>
                     </div>
                     
                     <div class="card-sub-title">Do you want your death notice to list your final place of residence?</div>
                     <div class="custom-button-yn">
                        <input id="residence-y" name="residence" value="yes" type="radio"  {{ isset($death_notice['include_final_place_of_residence']) && $death_notice['include_final_place_of_residence'] == 'yes' ? 'checked' : '' }}>
                        <label for="residence-y">Yes</label>
                        <input id="residence-n" name="residence" value="no" type="radio"  {{ !isset($death_notice['include_final_place_of_residence']) || $death_notice['include_final_place_of_residence'] == 'no' ? 'checked' : '' }}>
                        <label for="residence-n">No</label>
                     </div>
                 
               </div>
            </div>
            <!-- start previous / next buttons -->
            <div id="buttonsection">
               <div class="form-footer d-flex justify-content-between">
                  <div>
                  <button type="button" onclick="window.location.href = '{{ route('endoflifePlan.create.step.three_1') }}'" class="btn btn-light btn-lg back-btn">Back</button>
                  <button type="submit" class="btn btn-light btn-lg">Save and Continue</button>
               </div>
               <button type="submit" class="btn btn-light btn-lg" name="preview_submit" value="preview">{{env('PREVIEW_BUTTON_TEXT')}}</button>
                  <button type="button" class="btn btn-light btn-lg skip-btn d-none">Skip Step</button>
               </div>
            </div>
            <!-- end previous / next buttons -->
         </div>
      </div>
</div>

@endsection
@section('page-js')
<script src="{{ url('frontend/assets/js/forms/end-of-life-plan-multi-step.js?v=10.1.1') }}"></script>
<script src="{{ url('frontend/assets/js/forms/custom.js?v=10.3') }}"></script>
<script src="https://code.jquery.com/ui/1.13.2/jquery-ui.js"></script>
<script>
    $(function() {
       $( "#date_of_birth" ).datepicker({
          changeMonth: true, // Allow changing of month
          changeYear: true, // Allow changing of year
          dateFormat: 'mm-dd-yy' // Set the desired date format
       });
    });
 </script>
@endsection