
<?php  include "header.php";
include "includes/application-form-data.php";
 ?>
<!doctype html>
<html class="no-js" lang="zxx">

<head>

</head>

<body>


  <main>

      <!-- breadcrumb-area -->
      <section class="breadcrumb__area include-bg pt-150 pb-150 breadcrumb__overlay" data-background="assets/img/alevels/13.jpg">
         <div class="container">
            <div class="row">
               <div class="col-xxl-12">
                  <div class="breadcrumb__content p-relative z-index-1">
                     <h3 class="breadcrumb__title mb-20">Online Applcation Form <br> <?=$website_name;?></h3>
                     <div class="breadcrumb__list">
                        <span><a href="index.html">Home</a></span>
                        <span class="dvdr"><i class="fa-regular fa-angle-right"></i></span>
                        <span class="sub-page-black">Online Applcation Form</span>
                     </div>
                  </div>
               </div>
            </div>
         </div>
      </section>
      <!-- breadcrumb-area-end -->



      <!-- contact-area-end -->
      <section class="login-area pt-100 pb-100">
         <div class="container">
               <div class="row">
                  <div class="col-lg-8 offset-lg-2">
                     <div class="basic-login">
                           <h3 class="text-center mb-60">Begin Your Application with <?=$website_name; ?></h3>
                           <p> Please note that <?= $programmes[1]['name'];?> registration starts on <?= $programmes[1]['start_date'];?> and close on <?= $programmes[1]['end_date'];?>   </p>
                           <form action="confirmation.php" method="POST">
                              <fieldset class="programme-info">
                                 <legend>Section A - Programme Information</legend>
                                 <label for="programme">Choose Programme <span>**</span></label>
                                 <select  name="programme">
                                    <option value="null">Choose Programme</option>
                                    <?php foreach($programmes as $programme): ?>
                                    <option value="<?= $programme['name'];?>"><?= $programme['name'];?></option>
                                      <?php endforeach;?>
                                 </select>

                              </fieldset>

                               <fieldset class="programme-info">
                                 <legend>Section 2 - Applicant's Information</legend>

                                    <label for="firstname">First name <span>**</span></label>
                                    <input type="text" id="firstname" name="firstname">

                                    <label for="middlename">Middle name</label>
                                    <input type="text" id="middlename" name="middlename">

                                    <label for="name">Surname <span>**</span></label>
                                    <input type="text" id="surname" name="surname">

                                 <label for="dob">Date of Birth <span>**</span></label>
                                 <input type="date" id="dob" name="dob">

                                 <select id="programme" name="sex">
                                    <option value="null">Choose Sex</option>
                                    <option value="Male">Male</option>
                                    <option value="Female">Female</option>
                                 </select>

                                 <label for="religion">Religion</label>
                                 <select id="religion" name="religion">
                                    <option value="Christianity">Christianity</option>
                                    <option value="Islam">Islam</option>
                                    <option value="Others">Others</option>
                                 </select>

                                 <label for="maritalstatus">Marital Status</label>
                                 <select id="maritalstatus" name="maritalstatus">
                                    <option value="Single">Single</option>
                                    <option value="Married">Married</option>
                                    <option value="Divorced">Divorced</option>
                                 </select>

                              </fieldset>

                              <fieldset class="programme-info">
                                 <legend>Section C - Contact Information</legend>

                                 <label for="phone">Phone <span>**</span></label>
                                 <input type="tel" id="phone" name="phone">

                                 <label for="email">Email Address <span>**</span></label>
                                 <input type="email" id="email" name="email">

                                 <label for="residentialaddress">Residential Address</label>
                                 <textarea class="w-100" placeholder="Enter Your Residential Address" name="address"></textarea>



                                 <label for="nationality">Nationality <span>**</span></label>
                                 <select id="nationality" name="nationality">
                                    <option value="nigeria">No Country Selected</option>
                                     <?php foreach($countries as $i): ?>
                                    <option value="<?= $i ?>"><?= $i ?></option>
                                      <?php endforeach;?>
                                    <!-- Add more options here -->
                                 </select>

                                 <label for="state">State of Origin</label>
                                 <select id="state" name="state">
                                    <option value="null">No State Selected</option>
                                     <?php foreach($states as $i): ?>
                                    <option value="<?= $i; ?>"><?= $i; ?></option>
                                      <?php endforeach;?>

                                    <!-- Add more options here -->
                                 </select>

                                 <label for="lga">Local Govt. of Origin</label>
                                    <input type="text" id="lga" name="lga" placeholder="Enter Local Government of Origin">

                              </fieldset>

                              <fieldset class="programme-info">
                              <legend>Section D - Parent/Guardian's Information</legend>

                                <label for="parentname">Name: <span>**</span></label>
                              <input type="text" id="parentname" name="parentname">
                              <label for="parentoccupation">Occupation:</label>
                              <input type="text" id="parentoccupation" name="parentoccupation">
                              <label for="parentphone">Phone: <span>**</span></label>
                              <input type="tel" id="parentphone" name="parentphone">
                              <label for="parentemail">Email:</label>
                              <input type="email" id="parentemail" name="parentemail">
                              <label for="remarkaboutstudent">Remark about Student:</label>
                              <input type="text" id="remarkaboutstudent" name="remarkaboutstudent">
                              <label for="generalcomment">General comment about Applicant:</label>
                              <textarea class="w-100" name="generalcomment"></textarea>

                              </fieldset>


                                <fieldset class="programme-info">
                              <legend> Section E - Medical Report About Applicant</legend>

                                <label>Any Physical or Mental Challenges? <span>**</span></label>
                                <select name="challenges">
                                    <option value="null">Choose Option</option>
                                    <option value="Yes">Yes</option>
                                    <option value="No">No</option>
                                </select>

                                 <label>Any Allergies?</label>
                                <select name="allergies">
                                    <option value="null">Choose Option</option>
                                    <option value="Yes">Yes</option>
                                    <option value="No">No</option>
                                </select>

                                 <label for="bloodgroup">Blood Group</label>
                                <select name="bloodgroup">
                                    <option value="null">Choose Option</option>
                                    <option value="AA">AA</option>
                                    <option value="AS">AS</option>
                                    <option value="AC">AC</option>
                                    <option value="SS">SS</option>
                                    <option value="SC">SC</option>
                                    <!-- Add more options here -->
                                </select>

                                 <label for="genotype">Genotype</label>
                                 <select id="genotype" name="genotype">
                                    <option value="null">Choose Option</option>
                                    <option value="AA">AA</option>
                                    <option value="AS">AS</option>
                                    <option value="AC">AC</option>
                                    <option value="SS">SS</option>
                                    <option value="SC">SC</option>
                                    <!-- Add more options here -->
                                 </select>

                              </fieldset>

                              <fieldset class="programme-info">
                              <legend>Section F - Document Upload/Profiling</legend>
                                 <label for="image1">Passport Photograph</label>
                                 <input type="file" id="image1" name="passportphoto">
                                 <label for="image2">O'Level Result</label>
                                 <input type="file" id="image2" name="olevelresult">
                                 <label for="image3">Birth Certificate</label>
                                 <input type="file" id="image3" name="birthcertificate">
                                 <label for="image4">Other Document</label>
                                 <input type="file" id="image4" name="otherdocument">

                              </fieldset>

                              <fieldset class="programme-info">
                              <legend>Section G - Login Details</legend>
                              <label for="username">Username</label>
                              <input type="text" id="username" name="username">
                              <label for="password">Password</label>
                              <input type="password" id="password" name="password">


                              </fieldset>

                               <label for="confirm">Tick here to confirm that all details submitted are correct and accurate.</label>
                               <input type="checkbox" id="confirm" name="confirm" value="True">
                              <button name="submit" class="tp-btn w-100" type="submit">Submit Form</button>
                              <div class="or-divide"><span>or</span></div>
                              <a href="requirement.html" class="tp-border-btn w-100">View Requirement</a>
                           </form>
                     </div>
                  </div>
               </div>
         </div>
      </section>

      <!-- location-area -->
      <section class="location-area pt-120 pb-85">
         <div class="container">
          <div class="section-title mb-55">

                        <h2 class="tp-section-title mb-15 ">Do you need any help?</h2>
                         <span class="tp-sub-title mb-20">Don't Hesitate to Contact Us Now!</span>

                     </div>
            <div class="row">
               <div class="col-xl-4 col-md-6">
                  <div class="location-item text-center mb-30">
                     <div class="location-icon mb-25">
                        <i class="fa-light fa-location-dot"></i>
                     </div>
                     <div class="location-content">
                        <h5 class="location-title"><a href="#">Plot 3 & 5 Alesinloye GRA, Beside Alesinloye Market, Off Jericho, Dugbe, Ibadan, Oyo State Nigeria.</a></h5>
                     </div>
                  </div>
               </div>
               <div class="col-xl-4 col-md-6">
                  <div class="location-item text-center mb-30">
                     <div class="location-icon mb-25">
                        <i class=" fa-light fa-phone "></i>
                     </div>
                     <div class="location-content">
                        <h5 class="location-title"><a href="tel:+2349067058184">+234 (906) 705 8184</a></h5>
                        <h5 class="location-title"><a href="tel:+2348064038946">+234 (806) 403 8946</a></h5>
                        <h5 class="location-title"><a href="tel:+2349090909979">+234 (909) 090 9979</a></h5>
                     </div>
                  </div>
               </div>
               <div class="col-xl-4 col-md-6">
                  <div class="location-item text-center mb-30">
                     <div class="location-icon mb-25">
                        <i class="fi fi-rr-envelope"></i>
                     </div>
                     <div class="location-content">
                        <h5 class="location-title"><a href="mailto:enquiries@stcatherineschools.com.ng">enquiries@<br> stcatherineschools.com.ng</a></h5>
                         <h5 class="location-title"><a href="mailto:stcatherineschools@gmail.com">stcatherineschools@gmail.com</a></h5>
                     </div>
                  </div>
               </div>
            </div>
         </div>
      </section>
      <!-- location-area-end -->

      <!-- map-area -->
      <div class="map-area">
         <div class="map-wrapper">
            <iframe src="https://www.google.com/maps/embed?pb=!1m14!1m12!1m3!1d16421992.915334428!2d-74.54900526175051!3d53.308708074896664!2m3!1f0!2f0!3f0!3m2!1i1024!2i768!4f13.1!5e0!3m2!1sen!2sbd!4v1654426516184!5m2!1sen!2sbd" width="600" height="450" style="border:0;" allowfullscreen="" loading="lazy" referrerpolicy="no-referrer-when-downgrade"></iframe>
         </div>
      </div>
      <!-- map-area-end -->



   </main>

 <!-- footer-area -->
          <?php  include "footer.php" ?>
      <!-- footer-area-end -->




   <!-- JS here -->

</body>

</html>
