{% extends 'base.admin.html.twig' %}

{% block title %}Gestion - Enregistrer un cas{% endblock %}

{% block content %}
    <div class="animated fadeIn">
        <div class="row">
            <div class="col-lg-8 mx-auto">
                <div class="card">
                    <div class="card-header">
                        <strong class="card-title">Enregistrer un cas de VBG</strong>
                    </div>
                    <div class="card-body">
                        <div id="pay-invoice">
                            <div class="card-body">
                                <div class="card-title">
                                    <h4 class="text-center signalement-interne">
                                        <input id="ano-interne" type="checkbox"
                                               width="150" title="signalement anonyme"> Cochez cette case pour
                                        enregistrer un signalement ANONYME
                                    </h4>
                                </div>
                                <hr>
                                <form action="{{ path('signalement_interne') }}" method="post">
                                    <input type="hidden" name="token" value="{{ csrf_token('signalement_interne') }}" />
                                    <div class="form-group">
                                        <div>
                                            <div class="input-group">
                                                <span class="input-group-addon"><i
                                                            class="fa fa-globe"></i> {{ pays.getNom }}</span>
                                                <select name="pays" class="form-control" required>
                                                    <option value=""> Indiquez votre Région</option>
                                                    {% for region in pays.getRegions %}
                                                        <option value="{{ region.id }}">{{ region.nom }}</option>
                                                    {% endfor %}
                                                </select>
                                                <input name="pays" type="hidden" value="{{ pays.getId }}">
                                            </div>
                                        </div>
                                    </div>
                                    <div class="form-group">
                                        <div>
                                            <div class="input-group">
                                                <span class="input-group-addon"><i
                                                            class="fa fa-phone"></i> {{ pays.getIndicatif }}</span>
                                                <input id="phone" name="phone" class="form-control"
                                                       placeholder="Indiquez le numéro de téléphone..." type="text">
                                            </div>
                                        </div>
                                    </div>
                                    <div class="row" id="affiliations">
                                        <div class="col-xs-6 col-sm-6 col-md-6">
                                            <div class="form-group input-group">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"> <i class="fa fa-user"></i> </span>
                                                </div>
                                                <input name="prenom" id="ipt-prenom" class="form-control desactivable"
                                                       placeholder="Indiquez le prénom.." type="text"
                                                       required="required">
                                            </div>
                                        </div>
                                        <div class="col-xs-6 col-sm-6 col-md-6">
                                            <div class="form-group input-group">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"> <i class="fa fa-user"></i> </span>
                                                </div>
                                                <input name="nom" id="ipt-name" class="form-control desactivable"
                                                       placeholder="Indiquez le nom.." type="text" required="required">
                                            </div>
                                        </div>
                                    </div>
                                    <div class="form-group input-group">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"> <i class="fa fa-envelope"></i> </span>
                                        </div>
                                        <input name="email" class="form-control"
                                               placeholder="Indiquez l'adresse email.."
                                               type="email">
                                    </div>
                                    <div class="form-group input-group">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"> <i class="fas fa-sad-tear"></i> </span>
                                        </div>
                                        <select type="typesViolences" name="typesViolences" class="form-control" required>
                                            <option value=""> Précisez le type de violence</option>
                                            {% for violence in typesViolences %}
                                                <option data-formes-violences=""
                                                        value="{{ violence.id }}">{{ violence.type }}</option>
                                            {% endfor %}
                                        </select>
                                    </div>
                                    <div class="form-group input-group">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"> <i
                                                        class="fas fa-clipboard-list"></i> </span>
                                        </div>
                                        <select id="formesViolences" name="formesViolences" class="form-control" required>
                                            <option value=""> Précisez la forme de violence</option>
                                        </select>
                                    </div>
                                    <div class="form-group input-group">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"> <i class="fa fa-comment"></i> </span>
                                        </div>
                                        <textarea name="details" class="form-control" rows="4"
                                                  placeholder="Détails sur le cas de vbg que vous signalez.."></textarea>
                                    </div>
                                    <div>
                                        <button id="save-btn" type="submit" class="btn btn-lg btn-info btn-block">
                                            <i class="fa fa-check fa-lg"></i>&nbsp;
                                            <span id="payment-button-amount">Enregistrer</span>
                                        </button>
                                    </div>
                                </form>
                            </div>
                        </div>

                    </div>
                </div>
            </div>
        </div>
    </div>
{% endblock %}