2022-11-06 17:19:13 +00:00
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{{define "content"}}
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<div class="max-w-7xl mx-auto px-4 sm:px-6 md:px-8">
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<h1 class="text-2xl font-semibold text-gray-900">Ajouter un bénéficiaire</h1>
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</div>
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<div class="max-w-7xl mx-auto px-4 sm:px-6 md:px-8 mt-8"
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x-data="{
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fields: {
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first_name: null,
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last_name: null,
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email: null,
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phone_number: null,
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birthdate: null,
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file_number: null
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},
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rules: {
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first_name: ['required'],
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last_name: ['required'],
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email: ['required', 'email'],
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phone_number: ['required', 'regexMatch:^((\\+)33|0)[1-9](\\d{2}){4}$'],
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birthdate: ['required'],
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2023-04-12 08:52:29 +00:00
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file_number: ['required'],
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2022-11-06 17:19:13 +00:00
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},
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formValidation: {
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valid: false,
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fields: {
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first_name: {valid: null},
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last_name: {valid: null},
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email: {valid: null},
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phone_number: {valid: null},
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birthdate: {valid: null},
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file_number: {valid: null},
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}
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},
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isFormValid: true,
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validate() {
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this.formValidation = Iodine.assert(this.fields, this.rules)
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},
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validateField(field) {
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this.formValidation.fields[field] = Iodine.assert(this.fields[field], this.rules[field])
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},
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submit(event) {
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this.validate()
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if(!this.formValidation.valid) {
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this.isFormValid = false
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event.preventDefault()
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}
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return this.formValidation.valid
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}
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}">
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<form class="space-y-6" method="POST" @submit="submit">
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<div class="bg-white shadow px-4 py-5 sm:rounded-lg sm:p-6">
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<div class="md:grid md:grid-cols-3 md:gap-6">
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<div class="md:col-span-1">
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<h3 class="text-lg font-medium leading-6 text-gray-900">Informations obligatoires</h3>
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<p class="mt-1 text-sm text-gray-500">Informations personnelles sur le bénéficiaire obligatoires
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pour créer son profil dans PARCOURSMOB</p>
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</div>
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<div class="mt-5 md:mt-0 md:col-span-2">
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<div class="grid grid-cols-6 gap-6">
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<div class="col-span-6 sm:col-span-3">
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<label for="first_name" class="block text-sm font-medium text-gray-700">Prénom</label>
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<input type="text" name="first_name" id="first_name" autocomplete="given-name"
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class="mt-1 focus:ring-co-blue focus:border-co-blue block w-full shadow-sm sm:text-sm rounded-2xl"
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x-model="fields.first_name" @blur="validateField('first_name')"
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:class="formValidation.fields.first_name.valid == false ? 'border-co-red border-2' : 'border-gray-300'">
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</div>
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<div class="col-span-6 sm:col-span-3">
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<label for="last_name" class="block text-sm font-medium text-gray-700">Nom</label>
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<input type="text" name="last_name" id="last_name" autocomplete="family-name"
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class="mt-1 focus:ring-co-blue focus:border-co-blue block w-full shadow-sm sm:text-sm rounded-2xl"
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x-model="fields.last_name" @blur="validateField('last_name')"
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:class="formValidation.fields.last_name.valid == false ? 'border-co-red border-2' : 'border-gray-300'">
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</div>
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<div class="col-span-6 sm:col-span-3">
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<label for="email" class="block text-sm font-medium text-gray-700">Email</label>
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<input type="text" name="email" id="email" autocomplete="email"
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class="mt-1 focus:ring-co-blue focus:border-co-blue block w-full shadow-sm sm:text-sm rounded-2xl"
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x-model="fields.email" @blur="validateField('email')"
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:class="formValidation.fields.email.valid == false ? 'border-co-red border-2' : 'border-gray-300'">
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</div>
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<div class="col-span-6 sm:col-span-3">
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<label for="phone_number" class="block text-sm font-medium text-gray-700">Numéro de
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téléphone</label>
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<input type="text" name="phone_number" id="phone_number" autocomplete="phone" placeholder="+33612345678"
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class="mt-1 focus:ring-co-blue focus:border-co-blue block w-full shadow-sm sm:text-sm rounded-2xl"
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x-model="fields.phone_number" @blur="validateField('phone_number')"
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:class="formValidation.fields.phone_number.valid == false ? 'border-co-red border-2' : 'border-gray-300'">
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</div>
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<div class="col-span-6 sm:col-span-3">
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<label for="birthdate" class="block text-sm font-medium text-gray-700">Date de
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naissance</label>
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<input type="date" name="birthdate" id="birthdate" autocomplete="birthdate" placeholder="JJ/MM/AAAA"
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class="mt-1 focus:ring-co-blue focus:border-co-blue block w-full shadow-sm sm:text-sm rounded-2xl"
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x-model="fields.birthdate" @blur="validateField('birthdate')"
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:class="formValidation.fields.birthdate.valid == false ? 'border-co-red border-2' : 'border-gray-300'">
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</div>
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2023-04-12 08:52:29 +00:00
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<div class="col-span-6 sm:col-span-3">
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<label for="file_number" class="block text-sm font-medium text-gray-700">Numéro de dossier (CAF / Pole Emploi ...)</label>
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<input type="text" name="file_number" id="file_number" placeholder=""
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class="mt-1 focus:ring-co-blue focus:border-co-blue block w-full shadow-sm sm:text-sm rounded-2xl"
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x-model="fields.file_number" @blur="validateField('file_number')"
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:class="formValidation.fields.file_number.valid == false ? 'border-co-red border-2' : 'border-gray-300'">
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</div>
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2022-11-06 17:19:13 +00:00
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</div>
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</div>
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</div>
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</div>
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<div class="bg-white shadow px-4 py-5 sm:rounded-lg sm:p-6">
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<div class="md:grid md:grid-cols-3 md:gap-6">
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<div class="md:col-span-1">
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<h3 class="text-lg font-medium leading-6 text-gray-900">Informations optionnelles</h3>
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<p class="mt-1 text-sm text-gray-500">Autres informations de profil optionnelles</p>
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</div>
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<div class="mt-5 space-y-6 md:mt-0 md:col-span-2">
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<div class="grid grid-cols-6 gap-6">
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<div class="col-span-6 sm:col-span-3">
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<label for="gender" class="block text-sm font-medium text-gray-700">Genre</label>
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<div class="sm:mt-0 sm:col-span-2">
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<select id="gender" name="gender" autocomplete="gender" x-model="gender"
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class="max-w-lg mt-1 block focus:ring-co-blue focus:border-co-blue w-full shadow-sm sm:max-w-xs sm:text-sm border-gray-300 rounded-2xl">
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<option value="0">Inconnu</option>
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<option value="1">Masculin</option>
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<option value="2">Féminin</option>
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<option value="9">Sans objet</option>
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</select>
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</div>
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</div>
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<!-- <div class="col-span-3 sm:col-span-3">
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<label class="block text-sm font-medium text-gray-700"> Photo </label>
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<div class="mt-1 flex items-center space-x-5">
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<span class="inline-block h-12 w-12 rounded-co overflow-hidden bg-gray-100">
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{{.IconSet.Icon "img:profile-picture-placeholder" "h-full w-full"}}
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</span>
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<button type="button"
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class="bg-white py-2 px-3 border border-gray-300 rounded-2xl shadow-sm text-sm leading-4 font-medium text-gray-700 hover:bg-gray-50 focus:outline-none focus:ring-2 focus:ring-offset-2 focus:ring-co-blue">
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Charger la photo
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</button>
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</div>
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</div> -->
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</div>
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</div>
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</div>
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</div>
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<div class="bg-white shadow px-4 py-5 sm:rounded-lg sm:p-6">
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<div class="md:grid md:grid-cols-3 md:gap-6">
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<div class="md:col-span-1">
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<h3 class="text-lg font-medium leading-6 text-gray-900">Paramètres</h3>
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<p class="mt-1 text-sm text-gray-500">Paramètres liés au bénéficiaire, utiles pour exploiter les fonctionnalités de PARCOURSMOB</p>
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</div>
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<div class="mt-5 space-y-6 md:mt-0 md:col-span-2">
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{{ $fieldName := "address" }}
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{{ template "address_autocomplete" dict "FieldName" $fieldName }}
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<!-- will dolater : tags, groups, ... -->
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</div>
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</div>
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</div>
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<div class="flex justify-end">
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<p x-show="! isFormValid" class="px-4 py-2 text-sm text-co-red">Certains champs de sont pas valides.</p>
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<a href="/app/beneficiaries/">
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<button type="button"
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class="bg-white py-2 px-4 border border-gray-300 rounded-2xl shadow-sm text-sm font-medium text-gray-700 hover:bg-gray-50 focus:outline-none focus:ring-2 focus:ring-offset-2 focus:ring-co-blue">Annuler</button>
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</a>
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<button type="submit"
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class="ml-3 inline-flex justify-center py-2 px-4 border border-transparent shadow-sm text-sm font-medium rounded-2xl text-white bg-co-blue hover:bg-co-blue focus:outline-none focus:ring-2 focus:ring-offset-2 focus:ring-co-blue">Créer le bénéficiaire</button>
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</div>
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</form>
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</div>
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{{end}}
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