| Current File : /home/inlingua/public_html/sensoriumpsychologists.com/panel/franchise/student_registration.php |
<!DOCTYPE html>
<html>
<head>
<title>Shristi</title>
<?php require("../common/head_links.php");?>
</head>
<body class="hold-transition skin-blue sidebar-mini">
<div class="wrapper">
<?php require("common/header.php");?>
<?php require("common/left_side_bar.php");?>
<!-- Content Wrapper. Contains page content -->
<div class="content-wrapper">
<!-- Content Header (Page header) -->
<!-- Content Header (Page header) -->
<section class="content-header">
<h1> Student Registration</h1>
</section>
<!-- Main content -->
<section class="content">
<form role="form" method="post" enctype="multipart/form-data" onSubmit="return validate_form()">
<div class="row">
<!-- left column -->
<div class="col-md-6">
<!-- general form elements -->
<div class="box box-primary">
<div class="box-header with-border">
<h3 class="box-title">Login Details</h3>
</div>
<!-- /.box-header -->
<!-- form start -->
<div class="box-body">
<div class="form-group">
<label for="username">User name</label>
<input type="text" class="form-control" value="" disabled>
</div>
</div>
<!-- /.box-body -->
</div>
<!-- /.box -->
<div class="box box-primary">
<div class="box-header with-border">
<h3 class="box-title">Personal Details</h3>
</div>
<!-- /.box-header -->
<!-- form start -->
<div class="box-body">
<div class="form-group">
<label for="name">First Name </label>
<input type="text" class="form-control" id="first_name" name="name" value="">
</div>
<div class="form-group">
<label for="name">Last Name </label>
<input type="text" class="form-control" id="last_name" name="name" value="">
</div>
<div class="form-group">
<label>Date of Birth <span style="color:#F00;">*</span></label><br>
<select class="form-control col-xs-4" style="width:auto !important;" name="dob_day" id="dob_day">
<option value="">-Day-</option>
<option>1</option><option>2</option><option>3</option><option>4</option><option>5</option><option selected>6</option><option>7</option><option>8</option><option>9</option><option>10</option><option>11</option><option>12</option><option>13</option><option>14</option><option>15</option><option>16</option><option>17</option><option>18</option><option>19</option><option>20</option><option>21</option><option>22</option><option>23</option><option>24</option><option>25</option><option>26</option><option>27</option><option>28</option><option>29</option><option>30</option><option>31</option> </select>
<select class="form-control col-xs-4" style="width:auto !important;margin-left:10px;" name="dob_month" id="dob_month">
<option value="">-Month-</option>
<option
value="01">Jan</option>
<option
value="02">Feb</option>
<option
value="03">Mar</option>
<option
value="04">Apr</option>
<option
value="05">May</option>
<option
value="06">Jun</option>
<option
value="07">Jul</option>
<option
value="08">Aug</option>
<option
value="09">Sep</option>
<option
value="10">Oct</option>
<option
selected value="11">Nov</option>
<option
value="12">Dec</option>
</select>
<select class="form-control col-xs-4" style="width:auto !important;margin-left:10px;" name="dob_year" id="dob_year">
<option value="">-Year-</option>
<option>1948</option><option>1949</option><option>1950</option><option>1951</option><option>1952</option><option>1953</option><option>1954</option><option>1955</option><option>1956</option><option>1957</option><option>1958</option><option>1959</option><option>1960</option><option>1961</option><option>1962</option><option>1963</option><option>1964</option><option>1965</option><option>1966</option><option>1967</option><option>1968</option><option>1969</option><option>1970</option><option>1971</option><option>1972</option><option>1973</option><option>1974</option><option>1975</option><option>1976</option><option>1977</option><option>1978</option><option>1979</option><option selected>1980</option><option>1981</option><option>1982</option><option>1983</option><option>1984</option><option>1985</option><option>1986</option><option>1987</option><option>1988</option><option>1989</option><option>1990</option><option>1991</option><option>1992</option><option>1993</option><option>1994</option><option>1995</option><option>1996</option><option>1997</option><option>1998</option> </select>
</div>
<div class="clearfix"></div>
<div class="form-group" style="margin-top:20px;">
<label for="gender">Gender <span style="color:#F00;">*</span> : </label>
<label>
<input type="radio" name="gender" class="flat-red" value="male" style="position:relative;top:2px;"
checked
>
Male </label>
<label>
<input type="radio" name="gender" class="flat-red" value="female" style="position:relative;top:2px;" >
Female </label>
</div>
<div class="form-group">
<label for="father_name">Father Name <span style="color:#F00;">*</span></label>
<input type="text" class="form-control" id="father_name" name="father_name" style="text-transform:capitalize;" value="" >
</div>
<div class="form-group">
<label for="father_name">Mother Name <span style="color:#F00;">*</span></label>
<input type="text" class="form-control" id="mother_name" name="mother_name" style="text-transform:capitalize;" value="" >
</div>
</div>
<!-- /.box-body -->
</div>
<!-- /.box -->
<div class="box box-primary">
<div class="box-header with-border">
<h3 class="box-title">Contact Details</h3>
</div>
<!-- /.box-header -->
<!-- form start -->
<div class="box-body">
<div class="form-group">
<label for="contact_no">Contact No</label>
<input type="text" class="form-control" id="contact_no" name="contact_no" value="">
</div>
<div class="form-group">
<label for="alternate_contact_no">Alternate Contact No (if any)</label>
<input type="text" class="form-control" id="alternate_contact_no" onkeypress="return isNumberKey(event)" name="alternate_contact_no" value="" >
</div>
<div class="form-group">
<label for="email_id">Email ID </label>
<input type="email" class="form-control" id="email_id" style="text-transform:lowercase;" name="email_id" value="" >
</div>
</div>
<!-- /.box-body -->
</div>
<!-- /.box -->
</div>
<!--/.col (left) -->
<!-- right column -->
<div class="col-md-6">
<!-- Horizontal Form -->
<!-- form start -->
<div class="box box-primary">
<div class="box-header with-border">
<h3 class="box-title">Permanent Address <span style="color:#F00;">*</span></h3>
</div>
<!-- /.box-header -->
<!-- form start -->
<div class="box-body">
<div class="form-group">
<textarea class="form-control" name="p_local" id="p_local" rows="3" placeholder="Permanent Address" ></textarea>
</div>
<div class="form-group">
<input type="text" class="form-control" name="p_city" id="p_city" placeholder="City" style="text-transform:capitalize;" value="" />
</div>
<div class="form-group">
<select class="form-control" name="p_state" id="p_state" >
<option value="">-Select State-</option>
<option >Andaman & Nicobar</option>
<option >Andhra Pradesh</option>
<option >Arunachal Pradesh</option>
<option >Assam</option>
<option >Bihar</option>
<option >Chhattisgarh</option>
<option >Dadrar Nagar Haveli</option>
<option >Daman & Diu</option>
<option >Delhi</option>
<option >Goa</option>
<option >Gujarat</option>
<option >Haryana</option>
<option >Himachal Pradesh</option>
<option >Jammu & Kashmir</option>
<option >Jharkhand</option>
<option >Karnataka</option>
<option >Kerala</option>
<option >Lakshadweep</option>
<option >Madhya Pradesh</option>
<option >Maharashtra</option>
<option >Manipur</option>
<option >Meghalaya</option>
<option >Mizoram</option>
<option >Nagaland</option>
<option >Orissa</option>
<option >Pondicherry</option>
<option >Punjab</option>
<option >Rajasthan</option>
<option >Sikkim</option>
<option >Tamil Nadu</option>
<option >Telangana</option>
<option >Tripura</option>
<option >Uttar Pradesh</option>
<option >Uttaranchal</option>
<option >West Bengal</option>
</select>
</div>
<div class="form-group">
<input type="text" class="form-control" name="p_pincode" id="p_pincode" placeholder="Pincode" value="" maxlength="6" onkeypress="return isNumberKey(event)" />
</div>
</div>
<!-- /.box-body -->
</div>
<!-- /.box -->
<div class="box box-primary">
<div class="box-header with-border">
<h3 class="box-title">Correspondence Address <span style="color:#F00;">*</span> <input type="button" class="btn btn-primary" value="Copy Permanent" id="copy_addr_btn" onClick="copy_addr()" /></h3>
</div>
<!-- /.box-header -->
<!-- form start -->
<div class="box-body">
<div class="form-group">
<textarea class="form-control" name="c_local" id="c_local" rows="3" placeholder="Local Address" ></textarea>
</div>
<div class="form-group">
<input type="text" class="form-control" name="c_city" id="c_city" placeholder="City" style="text-transform:capitalize;" value="" />
</div>
<div class="form-group">
<select class="form-control" name="c_state" id="c_state">
<option value="">-Select State-</option>
<option >Andaman & Nicobar</option>
<option >Andhra Pradesh</option>
<option >Arunachal Pradesh</option>
<option >Assam</option>
<option >Bihar</option>
<option >Chhattisgarh</option>
<option >Dadrar Nagar Haveli</option>
<option >Daman & Diu</option>
<option >Delhi</option>
<option >Goa</option>
<option >Gujarat</option>
<option >Haryana</option>
<option >Himachal Pradesh</option>
<option >Jammu & Kashmir</option>
<option >Jharkhand</option>
<option >Karnataka</option>
<option >Kerala</option>
<option >Lakshadweep</option>
<option >Madhya Pradesh</option>
<option >Maharashtra</option>
<option >Manipur</option>
<option >Meghalaya</option>
<option >Mizoram</option>
<option >Nagaland</option>
<option >Orissa</option>
<option >Pondicherry</option>
<option >Punjab</option>
<option >Rajasthan</option>
<option >Sikkim</option>
<option >Tamil Nadu</option>
<option >Telangana</option>
<option >Tripura</option>
<option >Uttar Pradesh</option>
<option >Uttaranchal</option>
<option >West Bengal</option>
</select>
</div>
<div class="form-group">
<input type="text" class="form-control" name="c_pincode" id="c_pincode" placeholder="Pincode" value="" maxlength="6" onkeypress="return isNumberKey(event)" />
</div>
</div>
<!-- /.box-body -->
</div>
<!-- /.box -->
<div class="box box-primary">
<div class="box-header with-border">
<h3 class="box-title">Course Details</h3>
</div>
<!-- /.box-header -->
<!-- form start -->
<div class="box-body">
<div class="form-group">
<label for="">Course selected <span style="color:#F00;">*</span></label>
<input type="text" class="form-control" value="" name="" id="" >
</div>
<div class="form-group">
<label for="">Course Fees <span style="color:#F00;">*</span></label>
<input type="text" class="form-control" value="" name="" id="" >
</div>
<div class="form-group">
<label for="">Joining Batch <span style="color:#F00;">*</span></label><br>
<input type="text" class="form-control" name="" id="" value="" />
</div>
</div>
<!-- /.box-body -->
</div>
<!-- /.box -->
</div>
<!--/.col (right) -->
</div>
<div class="row">
<div class="col-md-12">
<div class="box box-primary">
<div class="box-header with-border">
<h3 class="box-title">Educational Qualification</h3>
</div>
<!-- /.box-header -->
<!-- form start -->
<div class="box-body">
<div class="form-group">
<div class="col-md-3">
</div>
<div class="col-md-3">
<label for=""><strong>Board/University</strong></label>
</div>
<div class="col-md-3">
<label for=""><strong>Year of Passing</strong></label>
</div>
<div class="col-md-3">
<label for=""><strong>Percentage of Marks</strong></label>
</div>
</div>
<div class="form-group">
<div class="col-md-3">
<label class="required" for="">Matriculation <span style="color:#F00;">*</span></label>
</div>
<div class="col-md-3">
<input id="" type="text" class="form-control" name="">
</div>
<div class="col-md-3">
<input id="" type="text" class="form-control" name="">
</div>
<div class="col-md-3">
<input id="" type="text" class="form-control" name="">
</div>
</div>
<div class="form-group">
<div class="col-md-3">
<label class="required" for="">Higher Secondary <span style="color:#F00;">*</span></label>
</div>
<div class="col-md-3">
<input id="" type="text" class="form-control" name="">
</div>
<div class="col-md-3">
<input id="" type="text" class="form-control" name="">
</div>
<div class="col-md-3">
<input id="" type="text" class="form-control" name="">
</div>
</div>
<div class="form-group">
<div class="col-md-3">
<label class="required" for="">Graduation <span style="color:#F00;">*</span></label>
</div>
<div class="col-md-3">
<input id="" type="text" class="form-control" name="">
</div>
<div class="col-md-3">
<input id="" type="text" class="form-control" name="">
</div>
<div class="col-md-3">
<input id="" type="text" class="form-control" name="">
</div>
</div>
<div class="form-group">
<div class="col-md-3">
<label class="required" for="">Other Qualification <span style="color:#F00;">*</span></label>
</div>
<div class="col-md-3">
<input id="" type="text" class="form-control" name="">
</div>
<div class="col-md-3">
<input id="" type="text" class="form-control" name="">
</div>
<div class="col-md-3">
<input id="" type="text" class="form-control" name="">
</div>
</div>
</div>
<!-- /.box-body -->
</div>
</div>
</div>
<!-- /.row -->
<div class="row">
<div class="col-md-12">
<button type="button" onClick="window.location.href='index.php'" class="btn btn-danger" style="margin-right:10px;margin-top:10px;">Back</button>
<button type="submit" class="btn btn-success" style="margin-top:10px;">Register</button>
</div>
</div>
</form>
</section>
<!-- /.content -->
</div><!-- /.content-wrapper -->
<?php require("../common/footer.php");?>
</div><!-- ./wrapper -->
<?php require("../common/footer_links.php");?>
</body>
</html>