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

@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.v2.End-Of-Life-Plan.stepIndicator')
    <form action="{{route('EndoflifePlanFormStore')}}" method="POST" id="signUpForm">
      @csrf
      <input type="hidden" id="stepInput" name="step" value="3-2-1">
      <div class="multiple-form dashboard-radio">
         <h4>Your death notice</h4>
         <p></p>

         <div class="form">
            <div class="row">
               <div class="col-12">
                  @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" id="birthplace" aria-describedby="nameHelp">
                     <small id="nameHelp" class="form-text text-muted">e.g. Hartford, Connecticut</small>
                  </div>
            
                  <p class="mt-5">Do you want your death notice to list your surviving family members?</p>

                  <div class="dashboard-radio-form">
                     <div class="form-check">
                        <input id="family_members-y" class="form-check-input" name="family_members" value="yes" type="radio" {{ isset($death_notice['include_surviving_family']) && $death_notice['include_surviving_family']  == 'yes' ? 'checked' : '' }}>
                        <label for="family_members-y"><p>Yes</p></label>
                     </div>
                     <div class="form-check">
                        <input id="family_members-n" class="form-check-input" name="family_members" value="no" type="radio" {{ isset($death_notice['include_surviving_family']) && $death_notice['include_surviving_family']  == 'no' ? 'checked' : '' }}>
                        <label for="family_members-n"><p>No</p></label>
                     </div>
                  </div>
                  
                  <p class="mt-5">Do you want your death notice to list your final place of residence?</p>

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

               </div>
            </div>
            <div id="buttonsection" class="submit-button-multiple">
               <button type="button" onclick="window.location.href = '{{ route('endoflifePlan.create.step.three_1') }}'">Back</button>
               <button type="submit" class="submit-btn">Save and Continue</button>
               <button type="submit" class="d-none" name="preview_submit" value="preview">{{env('PREVIEW_BUTTON_TEXT')}}</button>
               <button type="button" class="skip-btn d-none">Skip Step</button>
            </div>
         </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="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
         yearRange: "-200:+0", // Set range of selectable years
         maxDate: new Date() // Prevent selecting future dates
  
       });
    });
 </script>
 <script src="{{ url('v2/js/form-validation.js') }}?v={{ time() }}"></script>
@endsection