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

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

@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="3-4">
      <div class="multiple-form dashboard-radio">
         <h4>Organ donation</h4>
         <p>
         Are you a registered organ donor?
         <a tabindex="0"
            class="info-icon"
            role="button"
            data-bs-toggle="popover"
            data-bs-html="true"
            data-bs-trigger="focus"
            title="Organ Donor Information"
            data-bs-content="
               <p>Please note that expressing your wish to be an organ donor in this document is not sufficient on its own.</p>
               <p>You must also officially register as an organ donor through your local DMV or an approved online registry.</p>
            ">
            ?
         </a>
         </p>
         <span class="tooltiptext d-none">Note that you cannot simply state your desire to be an organ donor in this document. You must also register to be an organ donor at your local DMV or online.</span>
         <div class="form">
            <div class="row">
               <div class="col-12">
                  <div class="dashboard-radio-form">
                     <div class="form-check">
                        <input type="radio" class="form-check-input" id="organDonor-y" name="organDonor" value="yes" {{ isset($donor['organ_donor']) && $donor['organ_donor']  == "yes"  ? 'checked' : '' }}>
                        <label for="organDonor-y"><p>Yes</p></label>
                     </div>
                     <div class="form-check">
                        <input type="radio" class="form-check-input" id="organDonor-n" name="organDonor" value="no" {{ isset($donor['organ_donor']) && $donor['organ_donor']  == "no"  ? 'checked' : '' }}>
                        <label for="organDonor-n"><p>No</p></label>
                     </div>
                  </div>
                  <div id="organDonor-state">
                     <p class="mt-5">Where are you registered as a donor?</p>
                     <div class="form-group mb-3">
                        <label for="state">Country:</label>
                        {{-- <input type="text"  name="organDonorcountry" id="organDonorcountry" value="{{ isset($donor['country']) ? $donor['country'] : '' }}"> --}}
                        <input type="hidden" name="country_value" id="country_value" value="{{ isset($donor['country']) ? $donor['country'] : '1' }}"/>
                        <select id="country_dropdown_a" name="organDonorcountry" class="form-control" data-country-dropdown data-country-value="country_value" data-state-dropdown="state_dropdown_a" data-state-value="state_value">
                           <option value="">Select Country</option>
                        </select>
                     </div>
                     <div class="form-group mb-3">
                        <label for="state">State:</label>
                        {{-- <input type="text"  name="organDonorstate" id="organDonorstate" value="{{ isset($donor['state']) ? $donor['state'] : '' }}"> --}}
                        <input type="hidden" name="state_value" id="state_value"  value="{{ isset($donor['state']) ? $donor['state'] : '' }}"/>
                        <select id="state_dropdown_a" name="organDonorstate" class="form-control" data-state-dropdown>
                           <option value="">Select State</option>
                        </select>
                     </div>
                  </div>
               </div>
            </div>
         </div>
         <!-- start previous / next buttons -->
         <div id="buttonsection" class="submit-button-multiple">
               @if(isset($endoflifePlanForm->announcement) &&  $endoflifePlanForm->announcement == "no" )
               <button type="button" onclick="window.location.href = '{{ route('endoflifePlan.create.step.three') }}'">Back</button>
               @endif 
               @if(isset($endoflifePlanForm->announcement) &&  $endoflifePlanForm->announcement == "death" )
               <button type="button" onclick="window.location.href = '{{ route('endoflifePlan.create.step.three_2_3') }}'">Back</button>
               @endif 
               @if(isset($endoflifePlanForm->announcement) &&  $endoflifePlanForm->announcement == "obituary" ) 
               <button type="button" onclick="window.location.href = '{{ route('endoflifePlan.create.step.three_3_3') }}'">Back</button>
               @endif  
               <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>
         <!-- 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