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

{% block content %}

<div class="page-title">
  <div class="title_left">
    <h3>Enregistrer nouveau signal</h3>
  </div>
</div>

{% for message in app.flashes('notice') %}
        <div class="flash-notice navbar-right panel_toolbox alert alert-success">
            {{ message }}
        </div>
    {% endfor %}
<div class="clearfix"></div>

  

<div class="row">
    <div class="col-md-12 col-sm-12 ">
    <div class="x_panel">
        <div class="x_title">
        <h2>Nouveau </h2>
        
        <div class="clearfix"></div>
        </div>
        <div class="x_content">
        <br />
        <form id="signal-form" action="{{path('store_signal')}}" method="post" data-parsley-validate class="form-horizontal form-label-left">
            <input type="hidden" name="_csrf_token" value="{{ csrf_token('authenticate') }}">
            <div class="item form-group">
                <label class="col-form-label col-md-3 col-sm-3 label-align" for="prenom">Prénom
                </label>
                <div class="col-md-6 col-sm-6 ">
                    <input type="text" id="prenom" class="form-control " name="prenom" autofocus="true">
                </div>
            </div>

            <div class="item form-group">
                <label class="col-form-label col-md-3 col-sm-3 label-align" for="nom">Nom 
                </label>
                <div class="col-md-6 col-sm-6 ">
                    <input type="text" id="nom" name="nom" class="form-control">
                </div>
            </div>

             <div class="item form-group">
                <label class="col-form-label col-md-3 col-sm-3 label-align" for="pays">Pays <span class="required">*</span>
                </label>
                <div class="col-md-6 col-sm-6 ">
                    <select type="text" id="pays" required="required" name="pays" class="form-control "></select>
                </div>
            </div>

            <div class="item form-group">
                <label class="col-form-label col-md-3 col-sm-3 label-align" for="region">Region <span class="required">*</span>
                </label>
                <div class="col-md-6 col-sm-6 ">
                    <select type="text" id="region" name="region" required="required" class="form-control"></select>
                </div>
            </div>


             <div class="item form-group">
                <label class="col-form-label col-md-3 col-sm-3 label-align" for="telephone">Téléphone <span class="required">*</span>
                </label>
                <div class="col-md-6 col-sm-6 ">
                    <input type="text" id="telephone" required="required" name="telephone" class="form-control ">
                </div>
            </div>

            <div class="item form-group">
                <label class="col-form-label col-md-3 col-sm-3 label-align" for="email">Adresse email <span class="required">*</span>
                </label>
                <div class="col-md-6 col-sm-6 ">
                    <input type="email" id="email" name="email" required="required" class="form-control">
                </div>
            </div>

             <div class="item form-group">
                <label class="col-form-label col-md-3 col-sm-3 label-align" for="typeVilolence">Type de violence <span class="required">*</span>
                </label>
                <div class="col-md-6 col-sm-6 ">
                    <select type="text" id="typeViolence" required="required" name="typeViolence" class="form-control "> </select>
                </div>
            </div>

            <div class="item form-group">
                <label class="col-form-label col-md-3 col-sm-3 label-align" for="formeViolence">Forme de violence <span class="required">*</span>
                </label>
                <div class="col-md-6 col-sm-6 ">
                    <select type="text" id="formeViolence" name="formeViolence" required="required" class="form-control">
                    
                    </select>
                </div>
            </div>

            <div class="item form-group">
                <label class="col-form-label col-md-3 col-sm-3 label-align" for="description">Description de l'incident<span class="required">*</span>
                </label>
                <div class="col-md-6 col-sm-6 ">
                    <textarea type="text" id="description" name="description" required="required" class="form-control"> </textarea>
                </div>
            </div>


         
            
          
            <div class="ln_solid"></div>
            <div class="item form-group">
            <div class="col-md-6 col-sm-6 offset-md-3">

                <button class="btn btn-primary" type="reset">Annuler</button>
                <button type="submit" class="btn btn-success">Enregistrer</button>
            </div>
            </div>

        </form>
        </div>
    </div>
    </div>
</div>



{% endblock  %}

{% block script %}
<script>
    $(document).ready(function(){
        SignalFormController.init()
    });
</script>
{% endblock %}