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187 lines (177 loc) · 7.86 KB
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<?php include("inc/create.header.php"); ?>
<div id="create-profile">
<div class="cover">
<div class="container">
<img class="atrium-logo" src="/assets/img/atrium.png" alt="">
</div>
</div>
<div class="brand-gradient"></div>
<div class="container">
<div class="pro-form">
<h1>Create A Profile - <span class="acct-type">Professional Account</span></h1>
<form method="" >
<h2><span class="icon icon-personal-info"></span>Personal Information</h2>
<div class="form-group">
<div class="col-md-6">
<label>First Name</label>
<input type="text" class="form-control" name="first_name" placeholder="Enter First Name" required>
</div>
<div class="col-md-6">
<label>Last Name</label>
<input type="text" class="form-control" name="last_name" placeholder="Enter Last Name" required>
</div>
</div>
<div class="form-group">
<div class="col-md-6">
<label>Display Name - this is what users will see when you post</label>
<input type="text" class="form-control" name="username" placeholder="Enter username">
<label>Company / Organization Name</label>
<input type="text" class="form-control" name="organization" placeholder="Enter Company Name">
</div>
</div>
<div class="clearfix"></div>
<div class="form-group">
<div class="col-md-6">
<div class="form-group">
<label for="occupation">Occupation</label>
<div class="selectwrap">
<select class="form-control">
<option selected disabled>Choose Your Occupation</option>
<option>1</option>
<option>2</option>
<option>3</option>
<option>4</option>
</select>
</div>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label for="specialties">Specialties</label>
<div class="selectwrap">
<select class="form-control">
<option selected disabled>Select Specialties</option>
<option>1</option>
<option>2</option>
<option>3</option>
</select>
</div>
</div>
<div class="label-with-close">
Running
<a class="x" href="#"><span aria-hidden="true">×</span></a>
</div>
<div class="label-with-close">
Lifting
<a class="x" href="#"><span aria-hidden="true">×</span></a>
</div>
<div class="label-with-close">
Soccer
<a class="x" href="#"><span aria-hidden="true">×</span></a>
</div>
</div>
</div>
<div class="clearfix"></div>
<div class="col-md-6">
<div class="form-group">
<label for="dob">Date of Birth</label>
<div class="row">
<div class="col-sm-4 col-xs-6">
<div class="selectwrap">
<select class="form-control" name="dob">
<option selected disabled>Month</option>
<option value="01">Jan (01)</option>
<option value="02">Feb (02)</option>
<option value="03">Mar (03)</option>
<option value="04">Apr (04)</option>
<option value="05">May (05)</option>
<option value="06">June (06)</option>
<option value="07">July (07)</option>
<option value="08">Aug (08)</option>
<option value="09">Sep (09)</option>
<option value="10">Oct (10)</option>
<option value="11">Nov (11)</option>
<option value="12">Dec (12)</option>
</select>
</div>
</div>
<div class="col-sm-4 col-xs-6">
<div class="selectwrap">
<select class="form-control" name="day">
<option selected disabled>Day</option>
<option>01</option>
<option>02</option>
<option>03</option>
</select>
</div>
</div>
<div class="col-sm-4 col-xs-12">
<div class="selectwrap">
<select class="form-control" name="expiry-year">
<option selected disabled>Year</option>
<option value="13">2013</option>
<option value="14">2014</option>
<option value="15">2015</option>
<option value="16">2016</option>
<option value="17">2017</option>
<option value="18">2018</option>
<option value="19">2019</option>
<option value="20">2020</option>
<option value="21">2021</option>
<option value="22">2022</option>
<option value="23">2023</option>
</select>
</div>
</div>
</div>
<label for="dob">Gender</label>
<div class="row">
<div class="col-md-4 col-xs-6">
<div class="selectwrap">
<select class="form-control" name="gender">
<option selected disabled>Gender</option>
<option value="male">Male</option>
<option value="female">Female</option>
</select>
</div>
</div>
<div class="col-md-4 col-xs-6">
<input type="text" class="form-control" name="age" placeholder="Enter Age" required>
</div>
</div>
</div>
<div class="form-group">
<label>City</label>
<input type="text" class="form-control" name="city" placeholder="Enter your City" required>
<div class="row">
<div class="col-md-4">
<label>State</label>
<div class="selectwrap">
<select class="form-control" name="gender">
<option selected disabled>Select State</option>
<option>FL</option>
</select>
</div>
</div>
</div>
</div>
</div>
<div class="clearfix"></div>
<h2><span class="icon icon-certificate"></span>Credential Information</h2>
<p class="note">Note: We manually verify all our professionals ( takes 2-3 days )</p>
<div class="form-group top-gap-lg">
<div class="col-md-6">
<label>License / Certification Number</label>
<input type="text" class="form-control" name="first_name" placeholder="">
</div>
<div class="col-md-6">
<label>Accrediting Organization</label>
<input type="text" class="form-control" name="last_name" placeholder="">
</div>
</div>
</form>
</div>
<a class="btn save" type="submit" name="save" href="#">Save</a>
</div>
</div>
<?php include("inc/footer.php"); ?>