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248 lines (190 loc) · 10.4 KB
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<?php include('security.php'); ?>
<?php include('includes/header.php');?>
<?php include('includes/navbar.php');?>
<br><br><br><br>
<img src="img/volunteer/volunteer.jpg" style="height: auto; width: 100%; margin-top: 5px;" id="icons">
<div class="jumbotron" style="background-color: white;">
<form action="code.php" method="POST">
<div class="form-row ">
<div class="form-group col-md-4">
<label for="inputFullname">Full Name</label>
<input type="name" class="form-control" id="inputFullname" placeholder="Full Name" name="name" required="">
</div>
<div class="form-group col-md-4">
<label for="inputEmail4">Email Id</label>
<input type="email" class="form-control" id="inputPassword4" placeholder="Email" name="email" required="">
</div>
<div class="form-group col-md-4">
<label for="inputMobile">Mobile Number</label>
<input type="text" class="form-control" id="inputMobile" placeholder="Mobile Number" name="no" required="">
</div>
</div>
<div class="form-row">
<div class="form-group col-md-4">
<label for="inputGender">Gender</label>
<select id="inputGender" class="form-control" name="gen" required="">
<option selected>--Select--</option>
<option value="Male" name="gen">Male</option>
<option value="Female" name="gen">Female</option>
<option value="Other" name="gen">Other</option>
</select>
</div>
<div class="form-group col-md-4">
<label for="inputDOB">Date Of Birth</label>
<input type="date" class="form-control" id="inputDOB" placeholder="Date Of Birth" name="dob" required="">
</div>
<div class="form-group col-md-4">
<label for="inputAddress">Address</label>
<input type="text" class="form-control" id="inputAddress" placeholder="" name="add" required="">
</div>
</div>
<div class="form-row">
<div class="form-group col-md-4">
<label for="inputState">State</label> <select name="state" class="form-control" required="" >
<option>Select State</option>
<option name="state" value="andhra pradesh "> Andhra Pradesh</option>
<option name="state" value="arunachal pradesh " > Arunachal Pradesh </option>
<option name="state" value="assam " > Assam </option>
<option name="state" value="bihar " > Bihar </option>
<option name="state" value="chhattisgarh " > Chhattisgarh </option>
<option name="state" value="goa " > Goa </option>
<option name="state" value="gujarat " > Gujarat </option>
<option name="state" value="haryana " > Haryana </option>
<option name="state" value="himachal pradesh " > Himachal Pradesh </option>
<option name="state" value="jammu & kashmir " > Jammu & Kashmir </option>
<option name="state" value="jharkhand" > Jharkhand</option>
<option name="state" value="karnataka " > Karnataka </option>
<option name="state" value="kerala " > Kerala </option>
<option name="state" value="madhya pradesh " > Madhya Pradesh </option>
<option name="state" value="maharashtra " > Maharashtra </option>
<option name="state" value="manipur " > Manipur </option>
<option name="state" value="meghalaya " > Meghalaya </option>
<option name="state" value="mizoram " > Mizoram </option>
<option name="state" value="nagaland " > Nagaland </option>
<option name="state" value="orissa " > Orissa </option>
<option name="state" value="punjab " > Punjab </option>
<option name="state" value="rajasthan " > Rajasthan </option>
<option name="state" value="sikkim " > Sikkim </option>
<option name="state" value="tamil nadu " > Tamil Nadu </option>
<option name="state" value="telangana " > Telangana </option>
<option name="state" value="tripura " > Tripura </option>
<option name="state" value="uttar pradesh " > Uttar Pradesh </option>
<option name="state" value="uttarakhand " > Uttarakhand </option>
<option name="state" value="west bengal " > West Bengal </option>
<option name="state" value="andaman & nicobar islands " > Andaman & Nicobar Islands </option>
<option name="state" value="dadra and nagar haveli" > Dadra and Nagar Haveli</option>
<option name="state" value="daman and diu" > Daman and Diu</option>
<option name="state" value="lakshadweep " > Lakshadweep </option>
<option name="state" value="puducherry " > Puducherry </option>
<option name="state" value="delhi " > Delhi </option>
<option name="state" value="chandigarh " > Chandigarh </option>
</select>
</div>
<div class="form-group col-md-4">
<label for="inputCity">District</label>
<input type="text" class="form-control" id="inputCity" name="district" required="">
</div>
<div class="form-group col-md-4">
<label for="inputCity">City</label>
<input type="text" class="form-control" id="inputCity" name="city" required="">
</div>
</div>
<div class="form-row">
<div class="form-group col-md-4">
<label for="inputZip">PinCode</label>
<input type="text" class="form-control" id="inputZip" name="pincode" required="">
</div>
<div class="form-group col-md-8">
<label for="inputEdu">Availability</label>
<select id="inputEdu" class="form-control" name="avail" required="">
<option selected>--Select--</option>
<option name="im">Immediate</option>
<option name="24">24 Hour Notice</option>
</select>
</div>
</div>
<div class="jumbotron">
<div class="card ">
<div class="card-header">Essential Services</div>
<div class="card-body">
<div class="form-check">
<div class="form-check"><input class="form-check-input" type="checkbox" value="" id="defaultCheck1">
<label class="form-check-label" for="defaultCheck1">
Assisting District Administration in quarantine, home isolation and law and order arrangements
</label></div>
<div class="form-check"><input class="form-check-input" type="checkbox" value="" id="defaultCheck1">
<label class="form-check-label" for="defaultCheck1">
Disinfection and cleaning services</label></div>
<div class="form-check"><input class="form-check-input" type="checkbox" value="" id="defaultCheck1">
<label class="form-check-label" for="defaultCheck1">
Door to door information and service management</label></div>
</div>
</div>
</div>
<div class="card ">
<div class="card-header">Communication</div>
<div class="card-body">
<div class="form-check">
<div class="form-check"><input class="form-check-input" type="checkbox" value="" id="defaultCheck1">
<label class="form-check-label" for="defaultCheck1">
Public Awareness on Hygiene practices</label></div>
<div class="form-check"><input class="form-check-input" type="checkbox" value="" id="defaultCheck1">
<label class="form-check-label" for="defaultCheck1">
Promote social distancing measures</label></div>
<div class="form-check"><input class="form-check-input" type="checkbox" value="" id="defaultCheck1">
<label class="form-check-label" for="defaultCheck1">
Community level, RWA, Social Groups, Religious places awareness campaigns.</label></div>
<div class="form-check"><input class="form-check-input" type="checkbox" value="" id="defaultCheck1">
<label class="form-check-label" for="defaultCheck1">
Manning of help lines</label></div>
</div>
</div>
</div>
<div class="card ">
<div class="card-header">Health</div>
<div class="card-body">
<div class="form-check">
<div class="form-check"><input class="form-check-input" type="checkbox" value="" id="defaultCheck1">
<label class="form-check-label" for="defaultCheck1">
Paramedic</label></div>
<div class="form-check"><input class="form-check-input" type="checkbox" value="" id="defaultCheck1">
<label class="form-check-label" for="defaultCheck1">
Infection prevention and contro</label></div>
<div class="form-check"><input class="form-check-input" type="checkbox" value="" id="defaultCheck1">
<label class="form-check-label" for="defaultCheck1">
Assisting primary healthcare workers</label></div>
<div class="form-check"><input class="form-check-input" type="checkbox" value="" id="defaultCheck1">
<label class="form-check-label" for="defaultCheck1">
Helping elderly and those in need.</label></div>
<div class="form-check"><input class="form-check-input" type="checkbox" value="" id="defaultCheck1">
<label class="form-check-label" for="defaultCheck1">
Dead body management</label></div>
<div class="form-check"><input class="form-check-input" type="checkbox" value="" id="defaultCheck1">
<label class="form-check-label" for="defaultCheck1">
Transportation of patients</label></div>
</div>
</div>
</div>
<div class="card ">
<div class="card-header">Entrepreneurial</div>
<div class="card-body">
<div class="form-check">
<div class="form-check"><input class="form-check-input" type="checkbox" value="" id="defaultCheck1">
<label class="form-check-label" for="defaultCheck1">
Assisting in production of PPE, masks, sanitizers etc.
</label></div>
<div class="form-check"><input class="form-check-input" type="checkbox" value="" id="defaultCheck1">
<label class="form-check-label" for="defaultCheck1">
IT based solutions Logistics</label></div>
<div class="form-check"><input class="form-check-input" type="checkbox" value="" id="defaultCheck1">
<label class="form-check-label" for="defaultCheck1">
Logistics</label></div>
</div>
</div>
</div>
</div>
<button type="submit" class="btn btn-primary" name="indi_btn" style="margin-left: 40px;">Register</button>
</form>
</div>
<?php include('includes/scripts.php');?>
<?php include('includes/footer.php');?>