@extends('admin.layouts.layouts')
@section('header')
    @include('admin.partials.header')
@stop
@section('body')

    <div class="kt-container  kt-grid__item kt-grid__item--fluid kt-grid kt-grid--hor kt-grid--stretch">
        <div class="kt-body kt-grid__item kt-grid__item--fluid kt-grid kt-grid--hor kt-grid--stretch" id="kt_body">
            <div class="kt-content  kt-grid__item kt-grid__item--fluid kt-grid kt-grid--hor" id="kt_content">

                <!-- begin:: Content Head -->
                <div class="kt-subheader   kt-grid__item" id="kt_subheader">
                    <div class="kt-container ">
                        <div class="kt-subheader__main">

                            <h3 class="kt-subheader__title">Add New Applicaiton</h3>
                        </div>
                    </div>
                </div>
                <!-- end:: Content Head -->
                <!-- begin:: Content -->
                <div class="kt-container  kt-grid__item kt-grid__item--fluid">
                    <div class="row">
                        <div class="col-lg-12">
                            @if ($errors->any())
                                <div class="alert alert-warning">
                                    <ul>
                                        @foreach ($errors->all() as $error)
                                            <li>{{ $error }}</li>
                                        @endforeach
                                    </ul>
                                </div>
                                @endif
                                        <!--begin::Portlet-->
                                <div class="kt-portlet">
                                    <!--begin::Form-->
                                    {{--{{print_r($application[0])}}--}}
                                    {{--{{exit}}--}}
                                    <form class="kt-form kt-form--label-right">
                                        <input type="hidden" name="id" value="{{$application[0]->id}}">
                                        <div class="kt-portlet__body">
                                            <div class="form-group row form-group-marginless kt-margin-t-20">
                                                <label class="col-lg-2 col-form-label">First Name:</label>
                                                <div class="col-lg-3">
                                                    <input type="text" class="form-control" disabled="disabled" name="first_name" value='{{$application[0]->first_name}}' placeholder="First Name" required>
                                                    <span class="form-text text-muted">Please enter your first name</span>
                                                </div>
                                                <label class="col-lg-2 col-form-label">Last Name:</label>
                                                <div class="col-lg-3">
                                                    <input type="text" class="form-control" disabled="disabled" name="last_name"value='{{$application[0]->last_name}}' placeholder="Last Name" required>
                                                    <span class="form-text text-muted">Please enter your last name</span>
                                                </div>
                                            </div>

                                            <div class="kt-separator kt-separator--border-dashed kt-separator--space-lg kt-separator--portlet-fit"></div>

                                            {{--<div class="form-group row form-group-marginless kt-margin-t-20">--}}
                                                {{--<label class="col-lg-1 col-form-label">Applicant First Name:</label>--}}
                                                {{--<div class="col-lg-3">--}}
                                                    {{--<input type="text" class="form-control" disabled="disabled" name="app_first_name" value='{{$application[0]->app_first_name}}' placeholder="First Name" required>--}}
                                                    {{--<span class="form-text text-muted">Please enter your first name</span>--}}
                                                {{--</div>--}}
                                                {{--<label class="col-lg-1 col-form-label">Applicant Last Name:</label>--}}
                                                {{--<div class="col-lg-3">--}}
                                                    {{--<input type="text" class="form-control" disabled="disabled" name="app_last_name" value='{{$application[0]->app_last_name}}' placeholder="Last Name" required>--}}
                                                    {{--<span class="form-text text-muted">Please enter your last name</span>--}}
                                                {{--</div>--}}

                                                {{--<label class="col-lg-1 col-form-label" for="patient-rel">Patient is my</label>--}}
                                                {{--<div class="col-lg-2">--}}
                                                    {{--<select class="form-control" disabled="disabled" id="patient-rel" name="app_rel">--}}
                                                        {{--<option value="Self" {{ $application[0]->app_rel == 'Self' ? "selected" : '' }}>Self</option>--}}
                                                        {{--<option value="Spouse/Partner" {{ $application[0]->app_rel == 'Spouse/Partner' ? "selected" : '' }}>Spouse/Partner</option>--}}
                                                        {{--<option value="Child" {{ $application[0]->app_rel == 'Child' ? "selected" : '' }}>Child</option>--}}
                                                        {{--<option value="Grandchild" {{ $application[0]->app_rel == 'Grandchild' ? "selected" : '' }}>Grandchild</option>--}}
                                                        {{--<option value="Parent" {{ $application[0]->app_rel == 'Parent' ? "selected" : '' }}>Parent</option>--}}
                                                        {{--<option value="Grandparent" {{ $application[0]->app_rel == 'Grandparent' ? "selected" : '' }}>Grandparent</option>--}}
                                                        {{--<option value="Sibling" {{ $application[0]->app_rel == 'Sibling' ? "selected" : '' }}>Sibling</option>--}}
                                                        {{--<option value="Other" {{ $application[0]->app_rel == 'Other' ? "selected" : '' }}>Other</option>--}}
                                                    {{--</select>--}}
                                                {{--</div>--}}
                                            {{--</div>--}}

                                            {{--<div class="kt-separator kt-separator--border-dashed kt-separator--space-lg kt-separator--portlet-fit"></div>--}}

                                            <div class="form-group row form-group-marginless kt-margin-t-20">

                                                <label class="col-lg-1 col-form-label">Date of Birth:</label>
                                                <div class="col-lg-3">
                                                    <div class="input-group date">
                                                        <input type="text" class="form-control" disabled="disabled" name="do_birth" value='{{$application[0]->do_birth}}'  id="kt_datepicker_3" required>
                                                        <div class="input-group-append">
                                                    <span class="input-group-text">
                                                        <i class="la la-calendar"></i>
                                                    </span>
                                                        </div>
                                                    </div>
                                                </div>
                                                <label class="col-lg-1 col-form-label">Email Address:</label>
                                                <div class="col-lg-3">
                                                    <input type="email" class="form-control" disabled="disabled" name="email" value='{{$application[0]->email}}' placeholder="Email Address" required>
                                                    <span class="form-text text-muted">Please enter your Email Address</span>
                                                </div>
                                                <label class="col-lg-1 col-form-label">Home Phone:</label>
                                                <div class="col-lg-3">
                                                    <input type="text" class="form-control" disabled="disabled" name="h_phone" value='{{$application[0]->h_phone}}' placeholder="Enter home number" required>
                                                    <span class="form-text text-muted">Please enter your home number</span>
                                                </div>
                                            </div>

                                            <div class="kt-separator kt-separator--border-dashed kt-separator--space-lg kt-separator--portlet-fit"></div>

                                            <h4 class="kt-section__title">Home Address</h4>
                                            <div class="form-group row">
                                                <label class="col-lg-1 col-form-label">Address Line 1</label>
                                                <div class="col-lg-5">
                                                    <div class="kt-input-icon">
                                                        <input type="text" class="form-control" disabled="disabled" name="h_address_1" value='{{$application[0]->h_address_1}}' placeholder="Enter your Address Line 1" required>
                                                    </div>
                                                    <span class="form-text text-muted">Please enter your Address Line 1</span>
                                                </div>
                                                <label class="col-lg-1 col-form-label">Address Line 2</label>
                                                <div class="col-lg-5">
                                                    <input type="text" class="form-control" disabled="disabled" name="h_address_2" value='{{$application[0]->h_address_2}}' placeholder="Enter your Address Line 2" required>
                                                    <span class="form-text text-muted">Please enter your Address Line 2</span>
                                                </div>
                                            </div>
                                            <div class="form-group row">
                                                <label class="col-lg-1 col-form-label">City</label>
                                                <div class="col-lg-3">
                                                    <div class="kt-input-icon">
                                                        <input type="text" class="form-control" disabled="disabled" name="h_city" value='{{$application[0]->h_city}}' placeholder="Enter your City" required>
                                                    </div>
                                                    <span class="form-text text-muted">Please enter your City</span>
                                                </div>
                                                <label class="col-lg-1 col-form-label">State</label>
                                                <div class="col-lg-3">
                                                    <input type="text" class="form-control" disabled="disabled" name="h_state" value='{{$application[0]->h_state}}' placeholder="Enter your State" required>
                                                    <span class="form-text text-muted">Please enter your State</span>
                                                </div>
                                                <label class="col-lg-1 col-form-label">Zip Code</label>
                                                <div class="col-lg-3">
                                                    <input type="text" class="form-control" disabled="disabled"  name="h_zip_code" value='{{$application[0]->h_zip_code}}' placeholder="Enter your Zip Code" required>
                                                    <span class="form-text text-muted">Please enter your Zip Code</span>
                                                </div>
                                            </div>
                                            <div class="form-group row">
                                                <label class="col-3 col-form-label">Is this your current mailing address?</label>
                                                <div class="col-3">
                                                <span id='mailaddcheck' class="kt-switch kt-switch--icon">
                                                    <label>
                                                        <input type="checkbox" disabled="disabled" value='{{$application[0]->same_mail_add}}' {{ $application[0]->same_mail_add == '1' ? 'checked' : '' }}  name="same_mail_add">
                                                        <span></span>
                                                    </label>
                                                </span>
                                                </div>
                                            </div>
                                            <div id="mailadd" {{ $application[0]->same_mail_add == '1' ? 'style=display:none' : '' }}>
                                                <h4 class="kt-section__title">Mailing Address</h4>
                                                <div class="form-group row">
                                                    <label class="col-lg-1 col-form-label">Address Line 1</label>
                                                    <div class="col-lg-5">
                                                        <div class="kt-input-icon">
                                                            <input type="text" class="form-control" disabled="disabled" name="m_address_1" value='{{$application[0]->m_address_1}}' placeholder="Enter your Address Line 1">
                                                        </div>
                                                        <span class="form-text text-muted">Please enter your Address Line 1</span>
                                                    </div>
                                                    <label class="col-lg-1 col-form-label">Address Line 2</label>
                                                    <div class="col-lg-5">
                                                        <input type="text" class="form-control" disabled="disabled" name="m_address_2" value='{{$application[0]->m_address_2}}' placeholder="Enter your Address Line 2">
                                                        <span class="form-text text-muted">Please enter your Address Line 2</span>
                                                    </div>
                                                </div>
                                                <div class="form-group row">
                                                    <label class="col-lg-1 col-form-label">City</label>
                                                    <div class="col-lg-3">
                                                        <div class="kt-input-icon">
                                                            <input type="text" class="form-control" disabled="disabled" name="m_city" value='{{$application[0]->m_city}}' placeholder="Enter your City">
                                                        </div>
                                                        <span class="form-text text-muted">Please enter your City</span>
                                                    </div>
                                                    <label class="col-lg-1 col-form-label">State</label>
                                                    <div class="col-lg-3">
                                                        <input type="text" class="form-control" disabled="disabled" name="m_state" value='{{$application[0]->m_state}}' placeholder="Enter your State">
                                                        <span class="form-text text-muted">Please enter your State</span>
                                                    </div>
                                                    <label class="col-lg-1 col-form-label">Zip Code</label>
                                                    <div class="col-lg-3">
                                                        <input type="text" class="form-control" disabled="disabled" name="m_zip_code" value='{{$application[0]->m_zip_code}}' placeholder="Enter your Zip Code">
                                                        <span class="form-text text-muted">Please enter your Zip Code</span>
                                                    </div>
                                                </div>
                                            </div>

                                            <div class="kt-separator kt-separator--border-dashed kt-separator--space-lg kt-separator--portlet-fit"></div>

                                            <div class="form-group row">
                                                <label class="col-lg-2 col-form-label">Monthly Mortgage or Rent</label>
                                                <div class="col-lg-4">
                                                    <div class="input-group">
                                                        <div class="input-group-prepend"><span class="input-group-text">$</span></div>
                                                        <input type="text" class="form-control" disabled="disabled" name="house_rent" value='{{$application[0]->house_rent}}' placeholder="Per Month" required>
                                                    </div>
                                                </div>
                                                <label class="col-lg-2 col-form-label">Social Security:</label>
                                                <div class="col-lg-4">
                                                    <input type="text" class="form-control" disabled="disabled" name="social_security" value='{{$application[0]->social_security}}' placeholder="Social Security Number" required>
                                                    <span class="form-text text-muted">Please enter your Social Security</span>
                                                </div>
                                            </div>

                                            <div class="kt-separator kt-separator--border-dashed kt-separator--space-lg kt-separator--portlet-fit"></div>

                                            <div class="form-group row form-group-marginless kt-margin-t-20">
                                                <label class="col-lg-2 col-form-label">Amount Requested:</label>
                                                <div class="col-lg-4">
                                                    <div class="input-group">
                                                        <div class="input-group-prepend"><span class="input-group-text">$</span></div>
                                                        <input type="text" class="form-control" disabled="disabled" name="amount_required" value='{{$application[0]->amount_required}}' placeholder="Estimated Amount Requested" required>
                                                    </div>
                                                    <span class="form-text text-muted">Required Amount</span>
                                                </div>
                                                <label class="col-lg-2 col-form-label">Annual Gross Income</label>
                                                <div class="col-lg-4">
                                                    <div class="input-group">
                                                        <div class="input-group-prepend"><span class="input-group-text">$</span></div>
                                                        <input type="text" class="form-control" disabled="disabled" name="annual_gross_income" value='{{$application[0]->annual_gross_income}}' placeholder="Gross Yearly Individual Income" required>
                                                    </div>
                                                    <span class="form-text text-muted">Annual Gross Income</span>
                                                </div>
                                                {{--<label class="col-lg-1 col-form-label">Gross Yearly Additional Income:</label>--}}
                                                {{--<div class="col-lg-3">--}}
                                                    {{--<div class="input-group">--}}
                                                        {{--<div class="input-group-prepend"><span class="input-group-text">$</span></div>--}}
                                                        {{--<input type="text" class="form-control" disabled="disabled" name="gross_yearly_additional_income" value='{{$application[0]->gross_yearly_additional_income}}' placeholder="Gross Yearly Additional Income" required>--}}
                                                    {{--</div>--}}
                                                    {{--<span class="form-text text-muted">Please enter your Gross Yearly Additional Income</span>--}}
                                                {{--</div>--}}

                                            </div>

                                        </div>
                                        <div class="kt-portlet__foot">
                                            <div class="kt-form__actions">
                                                <div class="row">
                                                    <div class="col-lg-5"></div>
                                                    <div class="col-lg-7">
                                                        <button type="submit" class="btn btn-brand" disabled="disabled">Submit</button>
                                                        <button type="reset" class="btn btn-secondary">Cancel</button>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                        {!! csrf_field() !!}
                                    </form>
                                    <!--end::Form-->
                                </div>
                                <!--end::Portlet-->
                        </div>
                    </div>
                </div>
                <!-- end:: Content -->
                {{--</div>--}}
            </div>
        </div>
        @stop
        @section('footer')
            @include('admin.partials.footer')
@stop