<?php include 'header.php';?>
  <div class="content-page">
    <div class="content">
      <div class="container">
        
        
        
        <div class="row">
          <div class="col-md-12">
            <div class="panel panel-primary">
              <div class="panel-heading">
                <h3 class="panel-title">Add  Registeration Details</h3>
              </div>	
		
			
              <div class="panel-body">
                                    <div class="row"> 

               <form name="frm_add_category"  id="frm_add_category" method="post"action="insert_registration.php" >			

                        <div class="box-body">
						
							<div class="row">
							
							
							<div class="col-sm-4 col-xs-12">
                                            <div class="m-t-20">
							   <div class="form-group">
                                <label for="first_name" class="control-label">First Name</label>
               					 <input class="form-control" type="text" name="first_name" placeholder="First Name" />
                            </div>
</div></div>
							
							<div class="col-sm-4 col-xs-12">
                                            <div class="m-t-20">
							   <div class="form-group">
                                <label for="middle_name" class="control-label">Middle Name</label>
                				<input class="form-control" type="text" name="middle_name" placeholder="Middle Name" />
                            </div>
</div></div>
                     
					 <div class="col-sm-4 col-xs-12">
                                            <div class="m-t-20">       <div class="form-group">

                               <label for="last_name" class="control-label">Last Name</label>
                	<input class="form-control" type="text" name="last_name" placeholder="Last Name" required />

                            </div></div></div>
							
							</div>
							
							<div class="row">
							
							 <div class="col-sm-4 col-xs-12">
                                            <div class="m-t-20">
							<div class="form-group">

                                <label for="child_first_name" class="control-label">Child First Name</label>

                                 <input class="form-control" type="text" name="child_first_name" placeholder="Child First Name" />

                            </div></div></div>
							<div class="col-sm-4 col-xs-12">
                                            <div class="m-t-20">
							<div class="form-group">
							<label for="child_last_name" class="control-label">Child Last Name</label>

                                 <input class="form-control" type="text" name="child_last_name" placeholder="Child First Name" />

                            </div>
							</div></div></div>
							
							<div class="row">
							<div class="col-sm-2 col-xs-12">
                                            <div class="m-t-20">
							<div class="form-group">

                                <label for="age" class="control-label">Child Age</label>
                              <input class="form-control" type="text" name="age" placeholder="Age" required />

                            </div></div></div>
							<div class="col-sm-2 col-xs-12">
                                            <div class="m-t-20">
							
							<div class="form-group">

                             <label for="height" class="control-label">Child Height</label>

                              <input class="form-control" type="text" name="height" placeholder="Height" required />

                            </div></div></div>
							</div>
							
							<div class="row">
							<div class="col-sm-12 col-xs-12">
                            <div class="m-t-20">
							<div class="form-group">

                                <label for="Video Name" class="control-label">You want to Consult Dr. Ashish</label>

                                 <div class="input_field radio_option">
               <input type="radio" name="radiogroup1" id="rd1" value="Online">
              <label for="rd1">Online</label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
              <input type="radio" name="radiogroup1" id="rd2" value="In Person at Kanakaveda Clinic - Bandra">
              <label for="rd2">In Person at Kanakaveda Clinic - Bandra</label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			   <input type="radio" name="radiogroup1" id="rd3" value="In Person at Kanakaveda Clinic - Vasai">
              <label for="rd3">In Person at Kanakaveda Clinic - Vasai</label>
              </div>

                            </div></div></div>
							</div>
                            <div class="row">
							<div class="col-sm-12 col-xs-12">
                            <div class="m-t-20">
							<div class="form-group">

                                <label for="Video Name" class="control-label">Kanakaveda's Referance You Got From</label>
								<div class="input_field checkbox_option">
            	 <input type="checkbox" name="checkbox[]" id="checkbox" value="Kanakaveda's Patient">
    			<label for="cb1">
Kanakaveda's Patient</label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
 <input  type="checkbox" name="checkbox[]" id="checkbox" value="TV Interview">
    			<label for="cb2">
TV Interview</label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
 <input type="checkbox" name="checkbox[]" id="checkbox" value="YouTube">
    			<label for="cb3">
YouTube</label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
 <input  type="checkbox" name="checkbox[]" id="checkbox" value="Relative">
    			<label for="cb4">
Relative</label>
            </div>
			</div></div></div></div>
							<div class="row">
							<div class="col-sm-4 col-xs-12">
                            <div class="m-t-20">
							<div class="form-group">

                                <label for="email" class="control-label">Email</label>
							
							  <input class="form-control" type="email" name="email" placeholder="Email" required />
							</div></div></div>
							<div class="col-sm-4 col-xs-12">
                            <div class="m-t-20">
							<div class="form-group">

                                <label for="mobile" class="control-label">Mobile Number</label>
							
							        <input class="form-control" type="text" name="mobile" placeholder="Mobile Number" required />
							</div></div></div>
							<div class="col-sm-4 col-xs-12">
                            <div class="m-t-20">
							<div class="form-group">

                                <label for="city" class="control-label">City</label>
							
							 <input class="form-control" type="text" name="city" placeholder="City" required />
							</div></div></div>
							</div>
							
							
							<div class="row">
							<div class="col-sm-12 col-xs-12">
                            <div class="m-t-20">
							<div class="form-group">
							
		 <label class="control-label">Please Select A Program from below, according you will get detail information. (Excluding GST)*</label>
		 <div class="input_field radio_option">
              <input type="radio" name="radiogroup11" id="rd11" value="3 Months Program (Rs. 20000/-)">
              <label for="rd11">3 Months Program (Rs. 20000/-)</label><br>
               <input  type="radio" name="radiogroup11" id="rd12" value="6 Months Program (Rs. 36000/-)">
              <label for="rd2">
6 Months Program (Rs. 36000/-)</label><br>
			  <input type="radio" name="radiogroup11" id="rd13" value="12 Months Program ( Rs. 68000/-)">
              <label for="rd3">12 Months Program ( Rs. 68000/-)</label>
              </div>
			  </div></div></div>
							</div>
							
							
							<div class="row">
							<div class="col-sm-4 col-xs-12">
							<div class="m-t-20">
							<div class="form-group">
							<label class="control-label">Signature</label>
							   <input class="form-control" type="text" name="signature" placeholder="signature" required />
							</div>
							</div></div>
							</div>
							
                            <div class="col-sm-12 col-xs-12">
                                           
                                            <div class="m-t-20">
                                                    <div class="form-group">
                                                        <div>
                                                            <button type="submit" class="btn btn-primary waves-effect waves-light" style="float:right"> Submit </button>
							
															
                                                           
                                                        </div>
                                                    </div>
                                               
                                            </div>
                                        </div>

</div>

                    </form></div></div>
									
                                        
												
													


													
                                                    
                                        
                              </div>
            </div>
          </div>
        </div>
        
      </div>
    </div>
	<?php include 'footer.php';?>