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RPOD.php
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<!DOCTYPE html>
<html>
<head>
<title>Survey Registration</title>
<meta charset="UTF-8">
<link href='https://fonts.googleapis.com/css?family=Oswald:400,300,700' rel='stylesheet' type='text/css'>
<link href='https://fonts.googleapis.com/css?family=Source+Sans+Pro:400,400italic,600,600italic,700,700italic' rel='stylesheet' type='text/css'>
<link href='common/style.css' rel='stylesheet' type='text/css'>
<script src="http://code.jquery.com/jquery-latest.min.js"></script>
<meta name="viewport" content="width=device-width, initial-scale=1">
</head>
<body>
<div id="topbar">
<div class="container">
</div>
</div>
<div id="banner" >
<div class="container">
<div class="watermark">
<div class="wordmark">
</div>
</div>
<span class="clear"></span>
</div>
</div>
<div id="page_content">
<div class="pagetop">
</div>
<div class="container">
<div id="page_left">
<a>hi</a>
</div>
<div id="page_right">
<h1>Register for an account</h1>
<div class="alert alert-info">
<p>Welcome! This is the registration form for the survey, the registration form is linked to the survey in which the information you provide will be used in the questions for the survey. This is form is NOT used for the creation of an eID.</p>
</div>
<p style="color:#50017c;">An asterisk (*) denotes a required field.</p>
<form>
<fieldset>
<legend>Personal Information</legend>
<div class="row">
<div class="col-xs-12">
<label for="id_first_name" class="required">
First Name
</label>
<input type="text" name="firstName" value id="id_first_name" class="form-control textinput">
</div>
<div class="help col-md-6">
<h2 class="help__title">Given Name</h2>
</div>
</div>
<div class="row">
<div class="col-xs-12">
<label for="id_last_name" class="required">Last Name</label>
<input type="text" name="lastName" value="" id="id_last_name" class="form-control textinput">
</div><!-- form-group -->
<div class="help col-md-6">
<h2 class="help__title">Family Name</h2>
</div><!-- /help -->
</div>
<div class="row">
<div class="col-xs-12">
<label for="id_birthdate_month" class="required">Date of Birth</label>
<div>
<select name="dobMonth" id="id_birthdate_month" class=""><option value="">Month</option>
<option value="0">January</option>
<option value="1">February</option>
<option value="2">March</option>
<option value="3">April</option>
<option value="4">May</option>
<option value="5">June</option>
<option value="6">July</option>
<option value="7">August</option>
<option value="8">September</option>
<option value="9">October</option>
<option value="10">November</option>
<option value="11">December</option></select>
<select name="dobDays" id="id_birthdate_day" class=""><option value="">Day</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option></select>
<select name="dobYear" id="id_birthdate_year" class=""><option value="">Year</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
<option value="1941">1941</option>
<option value="1940">1940</option>
<option value="1939">1939</option>
<option value="1938">1938</option>
<option value="1937">1937</option>
<option value="1936">1936</option>
<option value="1935">1935</option>
<option value="1934">1934</option>
<option value="1933">1933</option>
<option value="1932">1932</option>
<option value="1931">1931</option>
<option value="1930">1930</option>
<option value="1929">1929</option>
<option value="1928">1928</option>
<option value="1927">1927</option>
<option value="1926">1926</option>
<option value="1925">1925</option>
<option value="1924">1924</option>
<option value="1923">1923</option>
<option value="1922">1922</option>
<option value="1921">1921</option>
<option value="1920">1920</option>
<option value="1919">1919</option>
<option value="1918">1918</option>
<option value="1917">1917</option>
<option value="1916">1916</option>
<option value="1915">1915</option>
<option value="1914">1914</option>
<option value="1913">1913</option>
<option value="1912">1912</option>
<option value="1911">1911</option></select>
</div>
</div>
</div>
<div class="row">
<div class=" col-xs-12">
<label for="id_gender" class="required">Gender</label>
<ul class="unstyled ">
<li>
<input type="radio" name="gender" value="M" id="id_male">
<label class="gender" for="id_male">Male</label>
</li>
<li>
<input type="radio" name="gender" value="F" id="id_female">
<label class="gender" for="id_female">Female</label>
</li>
</ul>
</div><!-- /form-group -->
</div>
<div class="row">
<div class="col-xs-12">
<label for="id_email" class="required">Email address</label>
<input type="text" name="alternateEmail" value="" id="id_email" class="form-control textinput">
</div><!-- /form-group -->
<div class="help col-md-6">
<h2 class="help__title">Email address</h2>
<p class="help__desc">To receive a registration confirmation email.</p>
<p class="help__desc">If you forget your password, an email to reset will be sent to this address.</p>
<!-- /help -->
</div>
<span class="clear"></span>
</div>
</fieldset>
<div class="form-group">
<input value="Continue" type="submit" onclick="goToAction('saveBaseInfo');return false;" id="submit_button" class="btn btn-primary" style="display: inline;">
</div>
<span class="clear"></span>
</form>
</div>
<span class="clear"></span>
<!--
Lorem ipsum isn't really real.
-->
</div> <!-- .container -->
<div class="pagebot">
</div>
<span class="clear"></span>
</div>
<div id="footer_nav">
<div class="container">
<span class="clear"></span>
</div>
</div>
<div id="footer">
<div class="container">
<h4>ACME, INC</h4>
123 Main St <span class="pipe">|</span> The towne, KS 23432<br>
PH <a href="tel:785.555.1234">785.555.1234</a> <span class="pipe">|</span> EM <a href="mailto:[email protected]">[email protected]</a>
</div>
</div>
</body>
<script src="common/nav_scripts.js"></script>
</html>