@section('form')
	<div class="row">
		<div class="col-md-2">
			<select class="form-control" name="title">
				<option value="MR" {{(isset($_REQUEST['title'])&&$_REQUEST['title']=="MR"?"selected='selected'":'')}}>{{Lang::get('format.MR')}}</option>
				<option value="MRS" {{(isset($_REQUEST['title'])&&$_REQUEST['title']=="MRS"?"selected='selected'":'')}}>{{Lang::get('format.MRS')}}</option>
				<option value="MS" {{(isset($_REQUEST['title'])&&$_REQUEST['title']=="MS"?"selected='selected'":'')}}>{{Lang::get('format.MS')}}</option>
				<option value="MSTR" {{(isset($_REQUEST['title'])&&$_REQUEST['title']=="MSTR"?"selected='selected'":'')}}>{{Lang::get('format.MSTR')}}</option>
				<option value="MISS" {{(isset($_REQUEST['title'])&&$_REQUEST['title']=="MISS"?"selected='selected'":'')}}>{{Lang::get('format.MISS')}}</option>
			</select>
		</div>

		<div class="col-md-2">
			<select class="form-control" name="sex">
				<option value="m" {{(isset($_REQUEST['sex'])&&$_REQUEST['sex']=="m"?"selected='selected'":'')}}>{{Lang::get('format.men')}}</option>
				<option value="w" {{(isset($_REQUEST['sex'])&&$_REQUEST['sex']=="w"?"selected='selected'":'')}}>{{Lang::get('format.women')}}</option>
			</select>
		</div>

		<div class="col-md-4">
                    @if(isset($erreurs['firstname']))
			<input placeholder="{{Lang::get('booking.firstname')}}" style="border: 1px solid red;" required="required" class="form-control" id="firstname" name="firstname" maxlength="28" size="30" type="text" value="{{(isset($_REQUEST['firstname'])?$_REQUEST['firstname']:'')}}">
                    @else
			<input placeholder="{{Lang::get('booking.firstname')}}" required="required" class="form-control" id="firstname" name="firstname" maxlength="28" size="30" type="text" value="{{(isset($_REQUEST['firstname'])?$_REQUEST['firstname']:'')}}">
                    @endif
		</div>

		<div class="col-md-4">
                    @if(isset($erreurs['lastname']))
			<input placeholder="{{Lang::get('booking.lastname')}}" style="border: 1px solid red;" required="required" class="form-control" id="lastname" name="lastname" maxlength="28" size="30" type="text" value="{{(isset($_REQUEST['lastname'])?$_REQUEST['lastname']:'')}}">
                    @else
			<input placeholder="{{Lang::get('booking.lastname')}}" required="required" class="form-control" id="lastname" name="lastname" maxlength="28" size="30" type="text" value="{{(isset($_REQUEST['lastname'])?$_REQUEST['lastname']:'')}}">
                    @endif
		</div>

		<br/><br/>

		<div class="col-md-4">
                    @if(isset($erreurs['email']))
			<input placeholder="{{Lang::get('booking.email')}}" style="border: 1px solid red;" required="required" class="form-control" id="email" name="email" type="text" value="{{(isset($_REQUEST['email'])?$_REQUEST['email']:'')}}">
                    @else
			<input placeholder="{{Lang::get('booking.email')}}" required="required" class="form-control" id="email" name="email" type="text" value="{{(isset($_REQUEST['email'])?$_REQUEST['email']:'')}}">
                    @endif
		</div>

		<div class="col-md-4">
                    @if(isset($erreurs['homephone']))
			<input placeholder="{{Lang::get('booking.phone')}}" style="border: 1px solid red;" class="form-control" id="homephone" name="homephone" type="text" value="{{(isset($_REQUEST['homephone'])?$_REQUEST['homephone']:'')}}">
                    @else
			<input placeholder="{{Lang::get('booking.phone')}}" class="form-control" id="homephone" name="homephone" type="text" value="{{(isset($_REQUEST['homephone'])?$_REQUEST['homephone']:'')}}">
                    @endif
		</div>

		<div class="col-md-4">
                    @if(isset($erreurs['cellphone']))
			<input placeholder="{{Lang::get('booking.cellphone')}}" style="border: 1px solid red;" class="form-control" id="cellphone" name="cellphone" type="text" value="{{(isset($_REQUEST['cellphone'])?$_REQUEST['cellphone']:'')}}">
                    @else
			<input placeholder="{{Lang::get('booking.cellphone')}}" class="form-control" id="cellphone" name="cellphone" type="text" value="{{(isset($_REQUEST['cellphone'])?$_REQUEST['cellphone']:'')}}">
                    @endif
		</div>

		<br/><br/>

		
		<div class="col-md-2">
			<select name="dob_dd" id="dob_dd" class="form-control">
				@for($i = 1; $i <= 31; $i++)
				<option value="{{(strlen($i)==1?'0':'').$i}}" {{(isset($_REQUEST['dob_dd'])&&$_REQUEST['dob_dd']==$i?"selected='selected'":'')}}>{{(strlen($i)==1?'0':'').$i}}</option>
				@endfor
			</select>
		</div>

		<div class="col-md-2">
			<select name="dob_mm" id="dob_mm" class="form-control">
				@for($i = 1; $i <= 12; $i++)
								<option value="{{(strlen($i)==1?'0':'').$i}}" {{(isset($_REQUEST['dob_mm'])&&$_REQUEST['dob_mm']==$i?"selected='selected'":'')}}>{{Lang::get('format.'.$label)}}</option>
				@endfor
			</select>
		</div>

		<div class="col-md-2">
			<select name="dob_yy" id="dob_yy" class="form-control">
								@for($i=$y;$i>=$yy;$i--)
				<option {{(isset($_REQUEST['dob_yy'])&&$_REQUEST['dob_yy']==$i?"selected='selected'":'')}}>{{$i}}</option>
				@endfor
			</select>
		</div>

		<div class="col-md-3">
			{{ Form::select('country', array() , null , array('class' => 'form-control' , 'id' => 'country')) }}
		</div>

		<div class="col-md-3">
			{{ Form::select('prov_state', array() , null , array('class' => 'form-control' , 'id' => 'prov_state')) }}
		</div>

		<br/><br/>

		<div class="col-md-4">
			<input placeholder="{{Lang::get('booking.city')}}" class="form-control" id="city" name="city" type="text" value="{{(isset($_REQUEST['city'])?$_REQUEST['city']:'')}}">
		</div>

		<div class="col-md-4">
			<input placeholder="{{Lang::get('booking.address')}}" class="form-control" id="adress" name="adress" type="text" value="{{(isset($_REQUEST['adress'])?$_REQUEST['adress']:'')}}">
		</div>

		<div class="col-md-2">
			<input placeholder="{{Lang::get('booking.zip')}}" class="form-control" id="zip" name="zip" type="text" value="{{(isset($_REQUEST['zip'])?$_REQUEST['zip']:'')}}">
		</div>

		<div class="col-md-2">
			{{ Form::select('lang', array('FR' => Lang::get('format.french'), 'EN' => Lang::get('format.english') ), (isset($_REQUEST['lang'])?$_REQUEST['lang']:null), array('class' => 'form-control' , 'style' => 'margin-bottom:5px', 'placeholder' => Lang::get('booking.language'))) }}
		</div>

                <div class="col-md-4">
                        <input placeholder="{{Lang::get('login.referred')}}" required="required" class="form-control" id="referral" name="referral" type="text" value="{{(isset($_REQUEST['referral'])?$_REQUEST['referral']:'')}}">
                </div>
                
		<div class="col-md-2">
			{{ Form::select('active', array('1' => Lang::get('account.activate'), '0' => Lang::get('account.desactivate') ), (isset($_REQUEST['active'])?$_REQUEST['active']:null), array('class' => 'form-control' , 'style' => 'margin-bottom:5px', 'placeholder' => Lang::get('account.activate'))) }}
		</div>

		<div class="col-md-3">
                    @if(isset($erreurs['password']))
                        <input placeholder="{{Lang::get('login.password')}}" style="border:1px solid red" class="form-control" id="password" name="password" type="password" value="">
                    @else
                        <input placeholder="{{Lang::get('login.password')}}" class="form-control" id="password" name="password" type="password" value="">
                    @endif
		</div>

		<div class="col-md-3">
                    @if(isset($erreurs['password_confirmation']))
			<input placeholder="{{Lang::get('login.confirmPassword')}}" style="border:1px solid red" class="form-control" id="password_confirmation" name="password_confirmation" type="password" value="">
                    @else
			<input placeholder="{{Lang::get('login.confirmPassword')}}" class="form-control" id="password_confirmation" name="password_confirmation" type="password" value="">
                    @endif
		</div>
	</div>
@stop