@extends('layouts.v2.frontend-user-backend')

@section('title', '| FREE END-OF-LIFE PLAN')

@section('content')
@include('frontend.forms.v2.End-Of-Life-Plan.stepIndicator')
 <!-- start -->

    <form action="{{route('EndoflifePlanFormStore')}}" method="POST" id="signUpForm">
      @csrf
      <input type="hidden" id="stepInput" name="step" value="4-1">
      <div class="multiple-form dashboard-radio">
        <div class="form">
            <div class="row">
               <div class="col-12">

                
                    @if(isset($endoflifePlanForm->remains) &&  $endoflifePlanForm->remains == "burial")
                        <h4>Burial instructions</h4>
                        <p>Would you like to leave specific instructions for your burial now?</p>

                                @php 
                                $selectedBurialTypes = json_decode($endoflifePlanForm->burialin_type, true);
                                @endphp
                                 <div class="dashboard-radio-form">
                                    <div class="form-check">
                                        <input id="burialin-y" class="form-check-input" name="burialin" type="radio" value="yes" {{ isset($selectedBurialTypes['burialin']) && $selectedBurialTypes['burialin'] === 'yes' ? 'checked' : '' }}>
                                        <label for="burialin-y"><p>Yes</p></label>
                                    </div>
                                    <div class="form-check">
                                        <input id="burialin-n" class="form-check-input" name="burialin" type="radio" value="no" {{ isset($selectedBurialTypes['burialin']) && $selectedBurialTypes['burialin'] === 'no' ? 'checked' : '' }}>
                                        <label for="burialin-n"><p>No</p></label>
                                    </div>
                                </div>
                                
                                <div id="burialin-sec" class="form-check-list">
                                    <p class="my-4">What details do you want to provide? (Select all that apply.)</p>
                                    <div class="form-check" id="form-check-label-custom">
                                        <label class="form-check-label">
                                            <input {{ isset($selectedBurialTypes['type']) && in_array('Final Resting Place', $selectedBurialTypes['type']) ? 'checked' : '' }} type="checkbox" class="form-check-input" name="burialintype[]" value="Final Resting Place">
                                            <p>Final Resting Place</p>
                                        </label>
                                    </div>
                                    <div class="form-check" id="form-check-label-custom">
                                        <label class="form-check-label">
                                            <input {{ isset($selectedBurialTypes['type']) && in_array('Embalmment', $selectedBurialTypes['type']) ? 'checked' : '' }} type="checkbox" class="form-check-input" name="burialintype[]" value="Embalmment">
                                            <p>Embalmment</p>
                                        </label>
                                    </div>
                                    <div class="form-check" id="form-check-label-custom">
                                        <label class="form-check-label">
                                            <input {{ isset($selectedBurialTypes['type']) &&  in_array('Casket', $selectedBurialTypes['type']) ? 'checked' : '' }} type="checkbox" class="form-check-input" name="burialintype[]" value="Casket">
                                            <p>Casket</p>
                                        </label>
                                    </div>
                                    <div class="form-check" id="form-check-label-custom">
                                        <label class="form-check-label">
                                            <input {{ isset($selectedBurialTypes['type']) &&  in_array('Headstone', $selectedBurialTypes['type']) ? 'checked' : '' }} type="checkbox" class="form-check-input" name="burialintype[]" value="Headstone">
                                            <p>Headstone</p>
                                        </label>
                                    </div>
                                    <div class="form-check" id="form-check-label-custom">
                                        <label class="form-check-label">
                                            <input {{ isset($selectedBurialTypes['type']) &&  in_array('Epitaph', $selectedBurialTypes['type']) ? 'checked' : '' }} type="checkbox" class="form-check-input" name="burialintype[]" value="Epitaph">
                                            <p>Epitaph</p>
                                        </label>
                                    </div>
                                    <div class="form-check" id="form-check-label-custom">
                                        <label class="form-check-label">
                                            <input {{ isset($selectedBurialTypes['type']) &&  in_array('Other', $selectedBurialTypes['type']) ? 'checked' : '' }} type="checkbox" class="form-check-input" name="burialintype[]" value="Other">
                                            <p>Other</p>
                                        </label>
                                    </div>
                                </div>
                                <div class="text-danger small fw-bold mt-2" id="BurialTypesError"></div>
                              
    
                    @endif
                    @if(isset($endoflifePlanForm->remains) &&  $endoflifePlanForm->remains == "mausoleum")
                        @php 
                        $selectedMausoleumTypes = json_decode($endoflifePlanForm->entombment_type, true);
                        @endphp

                            <h4>Entombment Instructions</h4>
                            <p>Would you like to leave specific instructions for your entombment now?</p>


                            <div class="dashboard-radio-form">
                                <div class="form-check">
                                    <input id="entombment-y" class="form-check-input" name="entombment" type="radio" value="yes" {{ isset($selectedMausoleumTypes['entombment']) && $selectedMausoleumTypes['entombment'] === 'yes' ? 'checked' : '' }}>
                                    <label for="entombment-y"><p>Yes</p></label>
                                </div>
                                <div class="form-check">
                                    <input id="entombment-n" class="form-check-input" name="entombment" type="radio" value="no" {{ isset($selectedMausoleumTypes['entombment']) && $selectedMausoleumTypes['entombment'] === 'no' ? 'checked' : '' }}>
                                    <label for="entombment-n"><p>No</p></label>
                                </div>
                            </div>
                            
                            <div id="entombment-sec" class="form-check-list">

                                <p class="my-4">What details do you want to provide? (Select all that apply.)</p>
                                <div class="form-check" id="form-check-label-custom">
                                    <label class="form-check-label">
                                        <input type="checkbox" class="form-check-input" name="entombmenttype[]" value="Final Resting Place" {{ isset($selectedMausoleumTypes['type']) && in_array('Final Resting Place', $selectedMausoleumTypes['type']) ? 'checked' : '' }}>
                                        <p>Final Resting Place</p>
                                    </label>
                                </div>
                                <div class="form-check" id="form-check-label-custom">
                                    <label class="form-check-label">
                                        <input type="checkbox" class="form-check-input" name="entombmenttype[]" value="Embalmment" {{ isset($selectedMausoleumTypes['type']) && in_array('Embalmment', $selectedMausoleumTypes['type']) ? 'checked' : '' }}>
                                        <p>Embalmment</p>
                                    </label>
                                </div>
                                <div class="form-check" id="form-check-label-custom">
                                    <label class="form-check-label">
                                        <input type="checkbox" class="form-check-input" name="entombmenttype[]" value="Casket" {{ isset($selectedMausoleumTypes['type']) && in_array('Casket', $selectedMausoleumTypes['type']) ? 'checked' : '' }}>
                                        <p>Casket</p>
                                    </label>
                                </div>
                                <div class="form-check" id="form-check-label-custom">
                                    <label class="form-check-label">
                                        <input type="checkbox" class="form-check-input" name="entombmenttype[]" value="Epitaph" {{ isset($selectedMausoleumTypes['type']) && in_array('Epitaph', $selectedMausoleumTypes['type']) ? 'checked' : '' }}>
                                        <p>Epitaph</p>
                                    </label>
                                </div>
                                <div class="form-check" id="form-check-label-custom">
                                    <label class="form-check-label">
                                        <input type="checkbox" class="form-check-input" name="entombmenttype[]" value="Other"  {{ isset($selectedMausoleumTypes['type']) && in_array('Other', $selectedMausoleumTypes['type']) ? 'checked' : '' }}>
                                        <p>Other</p>
                                    </label>
                                </div>
                            </div>
                            <div class="text-danger small fw-bold mt-2" id="entombmentError"></div>
                    @endif
                    @if(isset($endoflifePlanForm->remains) &&  $endoflifePlanForm->remains == "cremation")
                        <h4>Your remains</h4>
                        <p>What do you want done with your ashes?</p>
                        <div class="dashboard-radio-form">
                            <div class="form-check">
                                <input class="form-check-input" id="ashesnopreference" name="remainsashes" type="radio" value="nopreference">
                                <label for="ashesnopreference" class="marital-box" id="ashesnopreferencelabel">
                                    <p>No preference</p>
                                </label>
                            </div>
                            <div class="form-check">
                                <input class="form-check-input" id="ashesburial" name="remainsashes" type="radio" value="burial">
                                <label for="ashesburial" class="marital-box" id="ashesburiallabel">
                                    <p>Burial</p>
                                </label>
                            </div>
                            <div class="form-check">
                                <input class="form-check-input" id="ashescolumbarium" name="remainsashes" type="radio" value="columbarium">
                                <label for="ashescolumbarium" class="marital-box" id="ashescolumbariumlabel">
                                    <p>Held in a columbarium</p>
                                </label>
                            </div>
                            <div class="form-check">
                                <input class="form-check-input"  id="ashescremation" name="remainsashes" type="radio" value="loved">
                                <label for="ashescremation" class="marital-box" id="ashescremationlabel">
                                    <p>Given to a loved one</p>
                                </label>
                            </div>
                            <div class="form-check">
                                <input class="form-check-input" id="ashesdonationscience" name="remainsashes" type="radio" value="donationscience">
                                <label for="ashesdonationscience" class="marital-box" id="ashesdonationsciencelabel">
                                    <p>Scattered</p>
                                </label>
                            </div>
                            <div class="form-check">
                                <input class="form-check-input" id="ashesrother" name="remainsashes" type="radio" value="rother">
                                <label for="ashesrother" class="marital-box" id="ashesrotherlabel">
                                    <p>Other</p>
                                </label>
                            </div>
                        </div>
                    @endif
                    @if(isset($endoflifePlanForm->remains) &&  $endoflifePlanForm->remains == "donationscience")
                        @php 
                        $donation_organization = json_decode($endoflifePlanForm->donation_organization, true);
                        $donation_alternate = json_decode($endoflifePlanForm->donation_alternate, true);
                        @endphp
                        <h4>Donation details</h4>
                        <p>Do you want to name an alternate choice in case your original executor is unavailable?</p>
                        <div class="dashboard-radio-form">
                            <div class="form-check">
                                <input class="form-check-input" id="donation-y" name="donation" type="radio" value="yes"  {{ isset($donation_alternate['alternate']) && $donation_alternate['alternate'] === 'yes' ? 'checked' : '' }}>
                                <label for="donation-y"><p>Yes</p></label>
                            </div>
                            <div class="form-check">
                                <input class="form-check-input" id="donation-n" name="donation" type="radio" value="no"  {{ isset($donation_alternate['alternate']) && $donation_alternate['alternate'] === 'no' ? 'checked' : '' }}>
                                <label for="donation-n"><p>No</p></label>
                            </div>
                        </div>

                            <div id="donation-sec" class="child-card-holder">
                                <div class="card mb-3" id="child">
                                    <div class="card-body">
                                        <div class="form-group mb-3">
                                            <label>Name</label>
                                        <input type="text" class="form-control" name="donation_name" id="donation_name" aria-describedby="nameHelp" value="{{ isset($donation_alternate['name']) ?  $donation_alternate['name'] : '' }}">
                                        </div>
                                        <div class="form-group mb-3">
                                        <label>Address </label>
                                        <input type="text" class="form-control" name="donation_address" id="donation_address" aria-describedby="cityHelp"  value="{{ isset($donation_alternate['address']) ?  $donation_alternate['address'] : '' }}">
                                        <small id="cityHelp" class="form-text text-muted">e.g. Street, City, State ZIP Code</small>
                                        </div>
                                        <div class="form-group mb-3">
                                            <label>Phone Number </label>   
                                        <input type="text" class="form-control"  name="donation_phone" id="donation_phone" value="{{ isset($donation_alternate['phone']) ?  $donation_alternate['phone'] : '' }}">
                                        </div>
                                        <div class="form-group mb-3">
                                            <label>Email </label>
                                        <input type="text" class="form-control"  name="donation_email" id="donation_email"  value="{{ isset($donation_alternate['email']) ?  $donation_alternate['email'] : '' }}">
                                        </div>
                                    </div>
                                </div>
                            </div>

                            <div id="organization-holder">
                                <div id="organization">
                                    <p class="mt-4">Do you have a preferred program or organization?<p>
                                    <div class="dashboard-radio-form">
                                        <div class="form-check">
                                        <input id="organization-y" class="form-check-input"  name="organization" type="radio" value="yes" {{ isset($donation_organization['organization']) && $donation_organization['organization'] === 'yes' ? 'checked' : '' }}>
                                        <label for="organization-y"><p>Yes</p></label>
                                        </div>
                                        <div class="form-check">
                                        <input id="organization-n" class="form-check-input"  name="organization" type="radio" value="no" {{ isset($donation_organization['organization']) && $donation_organization['organization'] === 'no' ? 'checked' : '' }}>
                                        <label for="organization-n"><p>No</p></label>
                                        </div>
                                    </div>
                                </div>
                                <div id="organization-sec" class="child-card-holder">
                                    <div class="card mb-3" id="child">
                                        <div class="card-body">
                                            <div class="form-group mb-3">
                                                <label>Name</label>
                                                <input type="text" class="form-control" name="organization_name" id="organization_name" aria-describedby="nameHelp" value="{{isset($donation_organization['name']) ?  $donation_organization['name'] : '' }}">
                                            </div>
                                            <div class="form-group mb-3">
                                                <label>Address </label>
                                                <input type="text" class="form-control" name="organization_address" id="organization_address" aria-describedby="cityHelp"  value="{{isset($donation_organization['address']) ?  $donation_organization['address'] : '' }}">
                                                <small id="cityHelp" class="form-text text-muted">e.g. Street, City, State ZIP Code</small>
                                            </div>
                                            <div class="form-group mb-3">
                                                <label>Phone Number </label>
                                                <input type="text" class="form-control"  name="organization_phone" id="organization_phone"  value="{{isset($donation_organization['phone']) ?  $donation_organization['phone'] : '' }}">
                                            </div>
                                            <div class="form-group mb-3">
                                                <label>Email </label>
                                                <input type="text" class="form-control"  name="organization_email" id="organization_email"  value="{{isset($donation_organization['email']) ?  $donation_organization['email'] : '' }}" >
                                            </div>
                                        </div>
                                    </div>
                                </div>
                            </div>
                            
             

                    @endif
                    @if(isset($endoflifePlanForm->remains) &&  $endoflifePlanForm->remains == "other")
                        <h4>Remains Wishes</h4>
                        <p>How would you like your body to be disposed of?</p>

                        <div class="form-group mb-3">
                            <input type="text" class="form-control" name="remains_wishes" id="remains_wishes" aria-describedby="nameHelp" value="{{isset($endoflifePlanForm->body_disposed ) ? $endoflifePlanForm->body_disposed  : ''}}">
                            <small id="cityHelp" class="form-text text-muted">e.g. Upon my death, I want my body to be laid to rest at sea.</small>
                        </div>
                    
                    @endif
              
              </div>
           </div>
        </div>

        <!-- start previous / next buttons -->
        <div id="buttonsection" class="submit-button-multiple">
            <button type="button" onclick="window.location.href = '{{ route('endoflifePlan.create.step.four') }}'">Back</button>
            <button type="submit" class="submit-btn">Save and Continue</button>
            <button type="submit" name="preview_submit" class="d-none" value="preview">{{env('PREVIEW_BUTTON_TEXT')}}</button>
            <button type="button" class="skip-btn d-none">Skip Step</button>
        </div>
        <!-- end previous / next buttons -->

      </div>
    </form>
@endsection
@section('page-js')
<script src="{{ url('frontend/assets/js/forms/end-of-life-plan-multi-step.js') }}?v={{ time() }}"></script>
<script src="{{ url('frontend/assets/js/forms/custom.js?v=10.3') }}"></script>
<script src="{{ url('v2/js/form-validation.js') }}?v={{ time() }}"></script>
@endsection