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<html lang="en">
  <head>
  	<title>Contact Form 10</title>
    <meta charset="utf-8">
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	 <link rel="stylesheet" href="./style_signature.css">


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

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<script>
function validateForm() {
    
    var checkboxChecked = false;
    var checkboxes = document.getElementsByName("facing_problem[]");
    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. Facing Problem");
        return false;
    }
	}
</script>

<body>
<section class="ftco-section img bg-hero" style="background-image: url(bg1b.jpg);">
	
	 
	<div class="container">
		
	<div class="row justify-content-center">
			<div class="col-md-6 text-center mb-5">
				<img src="logo2.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">
							
							
							<div class="contact-wrap w-100 p-md-5 p-4"> 
								<h3><strong>Book An <?php echo $_REQUEST['event_name']?> Event </strong><span style="font-size:14px;"><br>www.kanakavedaayurveda.com</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_event.php" enctype="multipart/form-data" onSubmit="return validateForm()">
								  <input type="hidden" name="event_name" value="<?php echo $_REQUEST['event_name']?>">
								   <input type="hidden" name="eventID" value="<?php echo $_REQUEST['eventID']?>">
								   
								   
								   <label style="color:#000000"><strong>Is Your Child Facing Following Problem ?</strong></label><hr>
											<div class="row">
											
										
											
											<div class="col-md-12">
												<div class="form-group" >
												
				<input type="checkbox" name="facing_problem[]" id="checkbox1" value="Measles">
				<label for="checkbox1" style="color:#000000">Poor Appetite / भूक न लागणा</label><br>
											
				<input type="checkbox" name="facing_problem[]" id="checkbox2" value="Mumps">
				<label for="checkbox2" style="color:#000000">Weakness / शारीरिक कमजोरी</label><br>
				
				<input type="checkbox" name="facing_problem[]" id="checkbox3" value="Chickenpox">
				<label for="checkbox3" style="color:#000000">Offen stomach ache / हमेशा पेट मे दर्द</label><br>
				
				<input type="checkbox" name="facing_problem[]" id="checkbox4" value="Chicken Gunia">
				<label for="checkbox4" style="color:#000000">Constipation / कब्ज</label><br>
				
				<input type="checkbox" name="facing_problem[]" id="checkbox4" value="Maleria">
				<label for="checkbox4" style="color:#000000">Irritation / चिडचिडापन</label><br>
												
				<input type="checkbox" name="facing_problem[]" id="checkbox4" value="Jaundice">
				<label for="checkbox4" style="color:#000000">Poor Concentration / एकाग्रता का अभाव</label><br>
				
				<input type="checkbox" name="facing_problem[]" id="checkbox4" value="Typhoid">
				<label for="checkbox4" style="color:#000000">Poor Memory / स्मरणशक्ती की कमी</label><br>	
				
				<input type="checkbox" name="facing_problem[]" id="checkbox4" value="Renal Stone">
				<label for="checkbox4" style="color:#000000">Offen Sickness / हमेशा सर्दी / बुखार</label><br>
				
				
				<input type="checkbox" name="facing_problem[]" id="checkbox4" value="Gall Stone">
				<label for="checkbox4" style="color:#000000">Offen Headche / हमेशा सरदर्द</label><br>
				
				<input type="checkbox" name="facing_problem[]" id="checkbox4" value="Heart-Attack">
				<label for="checkbox4" style="color:#000000">Phobia / भय या डर</label><br>
				
			<input type="checkbox" name="facing_problem[]" id="checkbox4" value="Other">
				<input type="text" class="form-control" name="facing_problem_Other" placeholder="Other">
											
												
												</div></div>
												
												
											
											</div>
								 <label style="color:#000000"><strong>To Resolve these problems need to give Proper Diet and maintain daily Regimen of Your Child</strong></label><hr>
									<div class="row">
										<div class="col-md-12">
											<div class="form-group">
											
												<input type="text" class="form-control" name="child_name" placeholder="Name" required>
											</div>
										</div>
										<div class="col-md-12"> 
											<div class="form-group">
												<input type="text" class="form-control" name="std"  placeholder="Std.:" required>
											</div>
										</div>
										
										<div class="col-md-12"> 
											<div class="form-group">
												<input type="text" class="form-control" name="age"  placeholder="Age" required>
											</div>
										</div>
										
										<div class="col-md-12"> 
											<div class="form-group">
												<input type="text" class="form-control" name="year"  placeholder="Birth Year">
											</div>
										</div>
										
										<div class="col-md-12"> 
											<div class="form-group">
												<input type="text" class="form-control" name="school_name"  value="<?php echo $_REQUEST['school_name']?>" placeholder="School Name" required>
											</div>
										</div>
										
										<div class="col-md-12"> 
											<div class="form-group">
												<input type="text" class="form-control" name="parent_name" placeholder="Parent Name" required>
											</div>
										</div>
										
										
										<div class="col-md-12"> 
											<div class="form-group">
												<textarea name="address" class="form-control" placeholder="Address"></textarea>
											</div>
										</div>
										<div class="col-md-12"> 
											<div class="form-group">
												<input type="text" class="form-control" name="mobile_no"  placeholder="Mobile No" required pattern="[0-9]{10}">
											</div>
										</div>
											
										
											
											
											
										<div class="col-md-12">
											<div class="form-group">
											 <input class="btn btn-success" type="submit" onClick="saveSignature()" value="Register your Event" />
													
												<div class="submitting"></div>
											</div>
										</div>
									</div>	
								</form></div>
							</div>
						</div>
					</div>
				</div>
			</div>
		</div>
	</div>
</section>


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