<?php 
ob_start();   
session_start();
$conn=mysqli_connect("localhost","crmsahavasco","sa123AWEsadfa");
if(!$conn)
{
die("could not connect to".mysqli_error());
}
else
{
mysqli_select_db($conn,"crmsahavasco_kanakveda");
}
 $result = mysqli_query($conn,"SELECT * FROM appointment_details WHERE username='".$_REQUEST['username']."' AND password='".$_REQUEST['password']."'");
	
    if(mysqli_num_rows($result) > 0) {
      $_SESSION['is_logged_in'] = 1;
	  }
	if(isset($_SESSION['is_logged_in'])) {  
?>

<!doctype html>
<html lang="en">
  <head>
  	<title>Contact Form 10</title>
    <meta charset="utf-8">
    <meta name="viewport" content="width=device-width, initial-scale=1, shrink-to-fit=no">

	<link href='https://fonts.googleapis.com/css?family=Roboto:400,100,300,700' rel='stylesheet' type='text/css'>

	<link rel="stylesheet" href="https://stackpath.bootstrapcdn.com/font-awesome/4.7.0/css/font-awesome.min.css">
	<link href='https://fonts.googleapis.com/css?family=Roboto' rel='stylesheet'>
	 <link rel="stylesheet" href="./style_signature.css">


	<link rel="stylesheet" href="style_new.css">

	</head>
	
<script>
function validateForm() {
    
    var checkboxChecked = false;
    var checkboxes = document.getElementsByName("past_history[]");
    for (var i = 0; i < checkboxes.length; i++) {
        if (checkboxes[i].checked) {
            checkboxChecked = true;
            break;
        }
    }
	
	 if (!checkboxChecked) {
        alert("Please select at least one checkbox option. Past History");
        return false;
    }
	
	



// Menses
var checkboxCheckedMenses = false;
var checkboxesMenses = document.getElementsByName("menses[]");
for (var i = 0; i < checkboxesMenses.length; i++) {
    if (checkboxesMenses[i].checked) {
        checkboxCheckedMenses = true;
        break;
    }
}
if (!checkboxCheckedMenses) {
    alert("Please select at least one checkbox option for Menses.");
    return false;
}

// Leucorrhoea
var checkboxCheckedLeucorrhoea = false;
var checkboxesLeucorrhoea = document.getElementsByName("leucorrhoea[]");
for (var i = 0; i < checkboxesLeucorrhoea.length; i++) {
    if (checkboxesLeucorrhoea[i].checked) {
        checkboxCheckedLeucorrhoea = true;
        break;
    }
}
if (!checkboxCheckedLeucorrhoea) {
    alert("Please select at least one checkbox option for Leucorrhoea.");
    return false;
}


// Water Thirst
var checkboxCheckedWaterThirst = false;
var checkboxesWaterThirst = document.getElementsByName("water_thirst[]");
for (var i = 0; i < checkboxesWaterThirst.length; i++) {
    if (checkboxesWaterThirst[i].checked) {
        checkboxCheckedWaterThirst = true;
        break;
    }
}
if (!checkboxCheckedWaterThirst) {
    alert("Please select at least one checkbox option for Water Thirst.");
    return false;
}




// Appetite
var checkboxCheckedAppetite = false;
var checkboxesAppetite = document.getElementsByName("appetite[]");
for (var i = 0; i < checkboxesAppetite.length; i++) {
    if (checkboxesAppetite[i].checked) {
        checkboxCheckedAppetite = true;
        break;
    }
}
if (!checkboxCheckedAppetite) {
    alert("Please select at least one checkbox option for Appetite.");
    return false;
}

// Stool
var checkboxCheckedStool = false;
var checkboxesStool = document.getElementsByName("stool[]");
for (var i = 0; i < checkboxesStool.length; i++) {
    if (checkboxesStool[i].checked) {
        checkboxCheckedStool = true;
        break;
    }
}
if (!checkboxCheckedStool) {
    alert("Please select at least one checkbox option for Stool.");
    return false;
}

// Urine
var checkboxCheckedUrine = false;
var checkboxesUrine = document.getElementsByName("urine[]");
for (var i = 0; i < checkboxesUrine.length; i++) {
    if (checkboxesUrine[i].checked) {
        checkboxCheckedUrine = true;
        break;
    }
}
if (!checkboxCheckedUrine) {
    alert("Please select at least one checkbox option for Urine.");
    return false;
}

// Sleep
var checkboxCheckedSleep = false;
var checkboxesSleep = document.getElementsByName("sleep[]");
for (var i = 0; i < checkboxesSleep.length; i++) {
    if (checkboxesSleep[i].checked) {
        checkboxCheckedSleep = true;
        break;
    }
}
if (!checkboxCheckedSleep) {
    alert("Please select at least one checkbox option for Sleep.");
    return false;
}

// Perspiration
var checkboxCheckedPerspiration = false;
var checkboxesPerspiration = document.getElementsByName("perspiration[]");
for (var i = 0; i < checkboxesPerspiration.length; i++) {
    if (checkboxesPerspiration[i].checked) {
        checkboxCheckedPerspiration = true;
        break;
    }
}
if (!checkboxCheckedPerspiration) {
    alert("Please select at least one checkbox option for Perspiration.");
    return false;
}

// Rheatandcold
var checkboxCheckedRheatandcold = false;
var checkboxesRheatandcold = document.getElementsByName("Rheatandcold[]");
for (var i = 0; i < checkboxesRheatandcold.length; i++) {
    if (checkboxesRheatandcold[i].checked) {
        checkboxCheckedRheatandcold = true;
        break;
    }
}
if (!checkboxCheckedRheatandcold) {
    alert("Please select at least one checkbox option for Rheatandcold.");
    return false;
}

// Mind
var checkboxCheckedMind = false;
var checkboxesMind = document.getElementsByName("mind[]");
for (var i = 0; i < checkboxesMind.length; i++) {
    if (checkboxesMind[i].checked) {
        checkboxCheckedMind = true;
        break;
    }
}
if (!checkboxCheckedMind) {
    alert("Please select at least one checkbox option for Mind.");
    return false;
}







    return true; // Form is valid
}
</script>


	<body>
	<section class="ftco-section img bg-hero" style="background-image: url(bg1a.jpg);">
	
	 
		<div class="container">
		
		<div class="row justify-content-center">
				<div class="col-md-6 text-center mb-5">
					<img src="Kanakaveda.png" alt="logo">
				</div>
			</div>
			
			<div class="row justify-content-center">
				<div class="col-lg-11">
		
					<div class="wrapper">
						<div class="row no-gutters justify-content-between">
							
							<div class="col-lg-11">
							<?php
							$querynp = "select * from  case_form_master where case_form = '".$_REQUEST['case_form']."'";
$resultmp = mysqli_query($conn,$querynp);
while($row=mysqli_fetch_array($resultmp))
{
$case_step = $row['case_step'];

}?>
							
								<div class="contact-wrap w-100 p-md-5 p-4"> 
									<h3><strong>GROW WELL -Case Study Form - Step <?php echo $case_step;?></strong><span style="font-size:14px;"><br>Case Study Form</span></h3>
									
									<div id="form-message-warning" class="mb-4"></div> 
				      		<div id="form-message-success" class="mb-4">
				            Your message was sent, thank you!
				      		</div>
									  <form method="post" action="insert_case_study-B.php" enctype="multipart/form-data" onSubmit="return validateForm()">
							     <input type="hidden" name="appointment"  value="<?php echo $_REQUEST['appointment'];?>" /> 
								 <input type="hidden" name="username"  value="<?php echo $_REQUEST['username'];?>" /> 
								 <input type="hidden" name="password"  value="<?php echo $_REQUEST['password'];?>" />  
								  <input type="hidden" name="registration_id"  value="<?php echo $_REQUEST['registration_id'];?>" />  
								  
								  	  <input type="hidden" name="case_form"  value="<?php echo $_REQUEST['case_form'];?>" />  
								 
									<label style="color:#000000">Parent Details*</label><hr>
										<div class="row">
											<div class="col-md-12">
												<div class="form-group">
													<input type="date" class="form-control" name="form_date" placeholder="Date" required>
												</div>
											</div>
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="text" class="form-control" name="first_name"  placeholder="First Name" required>
												</div>
											</div>
											<div class="col-md-12">
												<div class="form-group">
													<input type="text" class="form-control" name="last_name" placeholder="Last Name" required>
												</div>
											</div>
											
											<div class="col-md-12">
												<div class="form-group">
													<input type="number" class="form-control" name="mobile_no" placeholder="Mobile" required pattern="[0-9]{10}">
												</div>
											</div>
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="date" class="form-control" name="birth_date"  placeholder="Birth Date" required>
												</div>
											</div>
											
											
											
											
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="number" class="form-control" name="child_height_cm"  placeholder="Height (In Cm )" required>
												</div>
											</div>
											
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="number" class="form-control" name="child_weight_kg"  placeholder="Weight in Kg." required>
												</div>
											</div>
											
										
											
										
											
									  </div>
											<label style="color:#000000"><strong>Address*</strong></label><hr>
											<div class="row">
											
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="text" class="form-control" name="address1"  placeholder="Street Address" required>
												</div>
											</div>
											
											
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="text" class="form-control" name="address2"  placeholder="Street Address Line 2" required>
												</div>
											</div>
											
											
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="text" class="form-control" name="city"  placeholder="City" required>
												</div>
											</div>
											
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="text" class="form-control" name="state"  placeholder="State / Province" required >
												</div>
											</div>
											
											
											<div class="col-md-12"> 
												<div class="form-group">
													<input type="text" class="form-control" name="zipcode"  placeholder="Postal / Zip Code" required  pattern="^\d{6}$">
												</div>
											</div>
											
											
											
											</div>
											
											<label style="color:#000000"><strong>Observation while treatment in 1st three months.</strong></label><hr>
											<div class="row">
											
											<div class="col-md-12"> 
												<div class="form-group">
													<textarea name="observation_treatment" class="form-control"  required="required"></textarea>
												</div>
											</div>
											</div>
											
											
											
											
											<label style="color:#000000"><strong>Past History of Any Disease:*</strong></label><hr>
											<div class="row">
											
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="past_history[]" id="checkbox1" value="Measles">
				<label for="checkbox1" style="color:#000000">Measles</label><br>
											
				<input type="checkbox" name="past_history[]" id="checkbox2" value="Mumps">
				<label for="checkbox2" style="color:#000000">Mumps</label><br>
				
				<input type="checkbox" name="past_history[]" id="checkbox3" value="Chickenpox">
				<label for="checkbox3" style="color:#000000">Chickenpox</label><br>
				
				<input type="checkbox" name="past_history[]" id="checkbox4" value="Chicken Gunia">
				<label for="checkbox4" style="color:#000000">Chicken Gunia</label><br>
				
				<input type="checkbox" name="past_history[]" id="checkbox4" value="Maleria">
				<label for="checkbox4" style="color:#000000">Maleria</label><br>
												
				<input type="checkbox" name="past_history[]" id="checkbox4" value="Jaundice">
				<label for="checkbox4" style="color:#000000">Jaundice</label><br>
				
				<input type="checkbox" name="past_history[]" id="checkbox4" value="Typhoid">
				<label for="checkbox4" style="color:#000000">Typhoid</label><br>	
				
				<input type="checkbox" name="past_history[]" id="checkbox4" value="Renal Stone">
				<label for="checkbox4" style="color:#000000">Renal Stone</label><br>
				
				
				<input type="checkbox" name="past_history[]" id="checkbox4" value="Gall Stone">
				<label for="checkbox4" style="color:#000000">Gall Stone</label><br>
				
				<input type="checkbox" name="past_history[]" id="checkbox4" value="Heart-Attack">
				<label for="checkbox4" style="color:#000000">Heart-Attack</label><br>
				
				<input type="checkbox" name="past_history[]" id="checkbox4" value="Piles">
				<label for="checkbox4" style="color:#000000">Piles</label><br>
				
				<input type="checkbox" name="past_history[]" id="checkbox4" value="Other">
				<input type="text" class="form-control" name="past_history_Other" placeholder="Other">
											
												
												</div></div>
												
												
											
											</div>
											
											<label style="color:#000000"><strong>Upload Reports</strong></label><hr>
											
												<div class="row">
											
										
            	 <div class="col-md-12"> 
												<div class="form-group">
				   <input type="file" class="file-form-control" name="medical_report" accept=".jpeg, .jpg, .png, .pdf, .doc, .docx">
           
          </div>  </div></div>
		  
		
												
											<hr>	
											
											<label style="color:#000000"><strong>Concentration Level Improves*</strong></label><hr>	
											
											
												
											<div class="row">
											
											<div class="col-md-12">
												<div class="form-group" >
												
									<input type="radio" name="concentration_level"  value="YES">
				<label for="checkbox1" style="color:#000000">YES</label><br>
											
				<input type="radio" name="concentration_level"  value="NO">
				<label for="checkbox2" style="color:#000000">NO</label><br>
				
				
				
				
												
												</div></div>
											
											</div>
											
											
												
											<hr>	
											
											<label style="color:#000000"><strong>Immunity Improves*</strong></label><hr>	
											
											
												
											<div class="row">
											
											<div class="col-md-12">
												<div class="form-group" >
												
									<input type="radio" name="immunity_improves"  value="YES">
				<label for="checkbox1" style="color:#000000">YES</label><br>
											
				<input type="radio" name="immunity_improves"  value="NO">
				<label for="checkbox2" style="color:#000000">NO</label><br>
				
				
				
				
												
												</div></div>
											
											</div>
											
											
											<hr>	
											
											<label style="color:#000000"><h3><strong>Obstetric and Gynecological History </strong></h3>For Femals</strong></label><hr>	
											
											
											

											
											<label style="color:#000000"><strong>Menses</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
									<input type="checkbox" name="menses[]" id="checkbox1" value="Regular">
				<label for="checkbox1" style="color:#000000">Regular</label><br>
											
				<input type="checkbox" name="menses[]" id="checkbox2" value="Irregular">
				<label for="checkbox2" style="color:#000000">Irregular</label><br>
				
				<input type="checkbox" name="menses[]" id="checkbox3" value="Profuse with Clots">
				<label for="checkbox3" style="color:#000000">Profuse with Clots</label><br>
				
				<input type="checkbox" name="menses[]" id="checkbox3" value="Absent">
				<label for="checkbox3" style="color:#000000">Absent</label><br>
												
												</div></div>
											
											</div>
											
											
											
											<label style="color:#000000"><strong>Leucorrhoea</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="leucorrhoea[]" id="checkbox1" value="YES">
				<label for="checkbox1" style="color:#000000">YES</label><br>
											
				<input type="checkbox" name="leucorrhoea[]" id="checkbox2" value="NO">
				<label for="checkbox2" style="color:#000000">NO</label><br>
				
				<input type="checkbox" name="leucorrhoea[]" id="checkbox3" value="White">
				<label for="checkbox3" style="color:#000000">White</label><br>
				
				<input type="checkbox" name="leucorrhoea[]" id="checkbox3" value="Yellowish">
				<label for="checkbox3" style="color:#000000">Yellowish</label><br>
				
				<input type="checkbox" name="leucorrhoea[]" id="checkbox3" value="Greenish">
				<label for="checkbox3" style="color:#000000">Greenish</label><br>
				
				<input type="checkbox" name="leucorrhoea[]" id="checkbox3" value="Offensive Smell">
				<label for="checkbox3" style="color:#000000">Offensive Smell</label><br>
												
												</div></div>
											
											</div>
												
											
											
											
											
											
											
											
											
												<hr>	
											
											<label style="color:#000000"><h3><strong>Generalities</strong></h3></label><hr>	
											
											
											

											
											
											
											
											
											<label style="color:#000000"><strong>Water Thirst*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="water_thirst[]" id="checkbox1" value="Normal">
				<label for="checkbox1" style="color:#000000">Normal</label><br>
											
				<input type="checkbox" name="water_thirst[]" id="checkbox2" value="Absent">
				<label for="checkbox2" style="color:#000000">Absent</label><br>
				
				<input type="checkbox" name="water_thirst[]" id="checkbox3" value="At a Time Small quantity at a small interval">
				<label for="checkbox3" style="color:#000000">At a Time Small quantity at a small interval</label><br>
				
				<input type="checkbox" name="water_thirst[]" id="checkbox3" value="At a Time Large quantity Large Interval.">
				<label for="checkbox3" style="color:#000000">At a Time Large quantity Large Interval.</label><br>
				
				
												
												</div></div>
											
											</div>
												
											
										
											
											<label style="color:#000000"><strong>Appetite*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="appetite[]" id="checkbox1" value="Normal">
				<label for="checkbox1" style="color:#000000">Normal</label><br>
											
				<input type="checkbox" name="appetite[]" id="checkbox2" value="Increase">
				<label for="checkbox2" style="color:#000000">Increase</label><br>
				
				<input type="checkbox" name="appetite[]" id="checkbox3" value="Absent">
				<label for="checkbox3" style="color:#000000">Absent</label><br>
				
				
												
				
				
												
												</div></div>
											
											</div>
											
											
											
											
											
												<hr>	
											
											<label style="color:#000000"><h3><strong>Bowel Habit</strong></h3></label><hr>	
											
											
											

											
											<label style="color:#000000"><strong>Stool</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="stool[]" id="checkbox1" value="Regular">
				<label for="checkbox1" style="color:#000000">Regular</label><br>
											
				<input type="checkbox" name="stool[]" id="checkbox2" value="Insufficient">
				<label for="checkbox2" style="color:#000000">Insufficient</label><br>
				
				<input type="checkbox" name="stool[]" id="checkbox3" value="Constipation">
				<label for="checkbox3" style="color:#000000">Constipation</label><br>
				
				<input type="checkbox" name="stool[]" id="checkbox3" value="Stool with Bleeding">
				<label for="checkbox3" style="color:#000000">Stool with Bleeding</label><br>
				
			
												
												</div></div>
											
											</div>
											
											
											
												<label style="color:#000000"><strong>Urine</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="urine[]" id="checkbox1" value="Normal">
				<label for="checkbox1" style="color:#000000">Normal</label><br>
											
				<input type="checkbox" name="urine[]" id="checkbox2" value="Increase">
				<label for="checkbox2" style="color:#000000">Increase</label><br>
				
				<input type="checkbox" name="urine[]" id="checkbox3" value="Absent">
				<label for="checkbox3" style="color:#000000">Absent</label><br>
				
				<input type="checkbox" name="urine[]" id="checkbox3" value="Involuntary Urination">
				<label for="checkbox3" style="color:#000000">Involuntary Urination</label><br>
				
			
												
												</div></div>
											
											</div>
											
											
											
											
												<label style="color:#000000"><strong>Sleep*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="sleep[]" id="checkbox1" value="Sound">
				<label for="checkbox1" style="color:#000000">Sound</label><br>
											
				<input type="checkbox" name="sleep[]" id="checkbox2" value="Increase">
				<label for="checkbox2" style="color:#000000">Increase</label><br>
				
				<input type="checkbox" name="sleep[]" id="checkbox3" value="Insomnia">
				<label for="checkbox3" style="color:#000000">Insomnia</label><br>
				
				<input type="checkbox" name="sleep[]" id="checkbox3" value="Disturbed">
				<label for="checkbox3" style="color:#000000">Disturbed</label><br>
				
			
												
												</div></div>
											
											</div>
											
											
											<label style="color:#000000"><strong>Perspiration*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="perspiration[]" id="checkbox1" value="Normal">
				<label for="checkbox1" style="color:#000000">Normal</label><br>
											
				<input type="checkbox" name="perspiration[]" id="checkbox2" value="Increase">
				<label for="checkbox2" style="color:#000000">Increase</label><br>
				
				<input type="checkbox" name="perspiration[]" id="checkbox3" value="Offensive">
				<label for="checkbox3" style="color:#000000">Offensive</label><br>
				
				
				
			
												
												</div></div>
											
											</div>
											
											
											
											
												<label style="color:#000000"><strong>Relation with Heat and Cold*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="Rheatandcold[]" id="checkbox1" value="Tolerate Cold">
				<label for="checkbox1" style="color:#000000">Tolerate Cold</label><br>
											
				<input type="checkbox" name="Rheatandcold[]" id="checkbox2" value="Tolerate Heat">
				<label for="checkbox2" style="color:#000000">Tolerate Heat</label><br>
				
				<input type="checkbox" name="Rheatandcold[]" id="checkbox3" value="Can Tolerate Both">
				<label for="checkbox3" style="color:#000000">Can Tolerate Both</label><br>
				
				<input type="checkbox" name="Rheatandcold[]" id="checkbox3" value="Can not Tolerate Both">
				<label for="checkbox3" style="color:#000000">Can not Tolerate Both</label><br>
				
			
												
												</div></div>
											
											</div>
											
												
											<label style="color:#000000"><strong>Mind / Manasikta*</strong></label><hr>							
											<div class="row">
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="mind[]" id="checkbox1" value="Sweet">
				<label for="checkbox1" style="color:#000000">Sweet</label><br>
											
				<input type="checkbox" name="mind[]" id="checkbox2" value="Spice">
				<label for="checkbox2" style="color:#000000">Spice</label><br>
				
				<input type="checkbox" name="mind[]" id="checkbox3" value="Sore">
				<label for="checkbox3" style="color:#000000">Sore</label><br>
				
				<input type="checkbox" name="mind[]" id="checkbox4" value="Salty">
				<label for="checkbox4" style="color:#000000">Salty</label><br>
				
				<input type="checkbox" name="mind[]" id="checkbox4" value="fruits">
				<label for="checkbox4" style="color:#000000">Fruits</label><br>
												
								
				<input type="checkbox" name="mind[]" id="checkbox4" value="Other">
				<input type="text" class="form-control" name="mind_other" placeholder="Other">
												
				
				
												
												</div></div>
											
											</div>
											
										
										
											
											
										
		  
		  <hr>
						<label style="color:#000000"><input type="checkbox" name="term_condition" id="checkbox1" value="Insets"> I agree to <a href="https://kanakavedaayurveda.com/kanakaveda-height-consent-form/" target="_blank">terms & conditions.</a> * </label>				
											  <hr>
		
		    <label for="typeahead" class="control-label" style="color:#000000">Draw Signature </label>
		<section class="signature-component">

  <canvas id="signature-pad" width="auto" height="100"></canvas>
  
 
</section>
<!-- partial -->


  <script src='https://cdnjs.cloudflare.com/ajax/libs/underscore.js/1.8.3/underscore-min.js'></script><script  src="./script.js"></script>

<!-- partial -->

				   <script>
        function saveSignature() {
            var canvas = document.getElementById('signature-pad');
            var dataURL = canvas.toDataURL(); // Get the image data

            // Send the image data to the PHP script
            var xhr = new XMLHttpRequest();
            xhr.open('POST', 'save_signature.php?name=123456', true);
            xhr.setRequestHeader('Content-type', 'application/x-www-form-urlencoded');
            xhr.onload = function() {
                if (xhr.status === 200) {
                    alert('Signature saved successfully.');
                } else {
                    alert('Failed to save signature.');
                }
            };
            xhr.send('imageData=' + encodeURIComponent(dataURL));
        }
    </script>
											
											
									
											
											
											
											<div class="col-md-12">
												<div class="form-group">
												 <input class="btn btn-success" type="submit" onClick="saveSignature()" value="Register your Program" />
													
													<div class="submitting"></div>
												</div>
											</div>
										</div>
									</form>
								</div>
							</div>
						</div>
					</div>
				</div>
			</div>
		</div>
	</section>


	<script src="js/jquery.min.js"></script>
  <script src="js/popper.js"></script>
  <script src="js/bootstrap.min.js"></script>
  <script src="js/jquery.validate.min.js"></script>
  <script src="js/main.js"></script>

	</body>
</html>

<?php } ?>