Repository navigation
Expand file tree
/
Copy pathindex.html
More file actions
115 lines (107 loc) · 4.98 KB
/
Copy pathindex.html
File metadata and controls
115 lines (107 loc) · 4.98 KB
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Romualdo - Registration Form</title>
<link rel="stylesheet" href="style.css">
<link rel="stylesheet" href="https://unicons.iconscout.com/release/v4.0.0/css/line.css">
</head>
<body>
<div class="container">
<header>
<span class="header-title">Registration Form</span>
<p class="header-sub">Please fill in all required fields marked with <span class="req">*</span></p>
</header>
<form id="regForm" novalidate>
<span class="title">Personal Information</span>
<div class="fields">
<div class="input-field">
<label>Last Name <span class="req">*</span></label>
<input type="text" name="lastName" placeholder="e.g. dela Cruz" required>
</div>
<div class="input-field">
<label>First Name <span class="req">*</span></label>
<input type="text" name="firstName" placeholder="e.g. Juan" required>
</div>
<div class="input-field">
<label>Middle Name</label>
<input type="text" name="middleName" placeholder="e.g. Santos">
</div>
<div class="input-field">
<label>Date of Birth <span class="req">*</span></label>
<input type="date" name="dob" required>
</div>
<div class="input-field">
<label>Gender <span class="req">*</span></label>
<select name="gender" required>
<option value="">Select gender</option>
<option>Male</option>
<option>Female</option>
<option>Non-binary</option>
<option>Prefer not to say</option>
</select>
</div>
<div class="input-field">
<label>Civil Status <span class="req">*</span></label>
<select name="civilStatus" required>
<option value="">Select status</option>
<option>Single</option>
<option>Married</option>
<option>Widowed</option>
<option>Separated</option>
<option>Annulled</option>
</select>
</div>
</div>
<span class="title">Contact Information</span>
<div class="fields">
<div class="input-field">
<label>Email Address <span class="req">*</span></label>
<input type="email" name="email" placeholder="e.g. juan@email.com" required>
</div>
<div class="input-field">
<label>Mobile Number <span class="req">*</span></label>
<input type="tel" name="phone" placeholder="e.g. 09171234567" required>
</div>
</div>
<span class="title">Address</span>
<div class="fields">
<div class="input-field full">
<label>House No. / Street <span class="req">*</span></label>
<input type="text" name="street" placeholder="e.g. 123 Rizal St." required>
</div>
<div class="input-field">
<label>Barangay <span class="req">*</span></label>
<input type="text" name="barangay" placeholder="e.g. Brgy. San Antonio" required>
</div>
<div class="input-field">
<label>City / Municipality <span class="req">*</span></label>
<input type="text" name="city" placeholder="e.g. Quezon City" required>
</div>
<div class="input-field">
<label>Province <span class="req">*</span></label>
<input type="text" name="province" placeholder="e.g. Metro Manila" required>
</div>
<div class="input-field">
<label>ZIP Code <span class="req">*</span></label>
<input type="text" name="zipCode" placeholder="e.g. 1100" required>
</div>
</div>
<div class="btn-group">
<button type="submit" class="submitBtn">
<span>Submit</span>
<i class="uil uil-check-circle"></i>
</button>
</div>
</form>
<div class="success-msg" id="successMsg">
<i class="uil uil-check-circle"></i>
<h3>Registration Submitted!</h3>
<p>Thank you for registering. Your information has been received.</p>
</div>
</div>
<script src="script.js"></script>
</body>
</html>