<div>
    <div class="image">
        <img src="<?php echo e(asset('public/assets/img/RaktveerLogo.png')); ?>" alt="">
    </div>
    <center>
        <h2>Register for blood donation</h2>
        <h4>16th Apr to 21 Apr 2023</h4>
    </center>
    <div class="form">
        <input type="number" placeholder="Phone Number / फ़ोन नंबर" id="phoneNumber" class="phone-number" wire:change="checkUser($event.target.value)" wire:model="username">
        <?php $__errorArgs = ['username'];
$__bag = $errors->getBag($__errorArgs[1] ?? 'default');
if ($__bag->has($__errorArgs[0])) :
if (isset($message)) { $__messageOriginal = $message; }
$message = $__bag->first($__errorArgs[0]); ?> <span class="error"><?php echo e($message); ?></span> <?php unset($message);
if (isset($__messageOriginal)) { $message = $__messageOriginal; }
endif;
unset($__errorArgs, $__bag); ?>

        <?php if($showForm): ?>
            <div class="form">
                
                <input type="text" placeholder="Name / नाम" class="input-box" wire:model="name">
                <?php $__errorArgs = ['name'];
$__bag = $errors->getBag($__errorArgs[1] ?? 'default');
if ($__bag->has($__errorArgs[0])) :
if (isset($message)) { $__messageOriginal = $message; }
$message = $__bag->first($__errorArgs[0]); ?> <span class="error"><?php echo e($message); ?></span> <?php unset($message);
if (isset($__messageOriginal)) { $message = $__messageOriginal; }
endif;
unset($__errorArgs, $__bag); ?>

                <input type="number" placeholder="Age / आयु" class="input-box" wire:model="age">
                <?php $__errorArgs = ['age'];
$__bag = $errors->getBag($__errorArgs[1] ?? 'default');
if ($__bag->has($__errorArgs[0])) :
if (isset($message)) { $__messageOriginal = $message; }
$message = $__bag->first($__errorArgs[0]); ?> <span class="error"><?php echo e($message); ?></span> <?php unset($message);
if (isset($__messageOriginal)) { $message = $__messageOriginal; }
endif;
unset($__errorArgs, $__bag); ?>

                <select class="input-box" name="" id="" wire:model="blood_group">
                    <option value="">Blood Group / रक्त समूह (ब्लड ग्रुप)</option>
                    <option value="A+">A+</option>
                    <option value="A-">A-</option>
                    <option value="B+">B+</option>
                    <option value="B-">B-</option>
                    <option value="AB+">AB+</option>
                    <option value="AB-">AB-</option>
                    <option value="O+">O+</option>
                    <option value="O-">O-</option>
                </select>
                <?php $__errorArgs = ['blood_group'];
$__bag = $errors->getBag($__errorArgs[1] ?? 'default');
if ($__bag->has($__errorArgs[0])) :
if (isset($message)) { $__messageOriginal = $message; }
$message = $__bag->first($__errorArgs[0]); ?> <span class="error"><?php echo e($message); ?></span> <?php unset($message);
if (isset($__messageOriginal)) { $message = $__messageOriginal; }
endif;
unset($__errorArgs, $__bag); ?>

                <select class="input-box" name="" id="" wire:model="district">
                    <option value="">District / जिला</option>
                    <?php $__currentLoopData = $districts; $__env->addLoop($__currentLoopData); foreach($__currentLoopData as $district): $__env->incrementLoopIndices(); $loop = $__env->getLastLoop(); ?>
                        <option value="<?php echo e($district->id); ?>"><?php echo e($district->name); ?></option>
                    <?php endforeach; $__env->popLoop(); $loop = $__env->getLastLoop(); ?>
                </select>
                <?php $__errorArgs = ['district'];
$__bag = $errors->getBag($__errorArgs[1] ?? 'default');
if ($__bag->has($__errorArgs[0])) :
if (isset($message)) { $__messageOriginal = $message; }
$message = $__bag->first($__errorArgs[0]); ?> <span class="error"><?php echo e($message); ?></span> <?php unset($message);
if (isset($__messageOriginal)) { $message = $__messageOriginal; }
endif;
unset($__errorArgs, $__bag); ?>

                <select class="input-box" name="" id="" wire:model="assembly">
                    <option value="">Assembly / विधानसभा</option>
                    <?php $__currentLoopData = $assemblies; $__env->addLoop($__currentLoopData); foreach($__currentLoopData as $assembly): $__env->incrementLoopIndices(); $loop = $__env->getLastLoop(); ?>
                        <option value="<?php echo e($assembly->id); ?>"><?php echo e($assembly->name); ?></option>
                    <?php endforeach; $__env->popLoop(); $loop = $__env->getLastLoop(); ?>
                </select>
                <?php $__errorArgs = ['assembly'];
$__bag = $errors->getBag($__errorArgs[1] ?? 'default');
if ($__bag->has($__errorArgs[0])) :
if (isset($message)) { $__messageOriginal = $message; }
$message = $__bag->first($__errorArgs[0]); ?> <span class="error"><?php echo e($message); ?></span> <?php unset($message);
if (isset($__messageOriginal)) { $message = $__messageOriginal; }
endif;
unset($__errorArgs, $__bag); ?>

                <input class="input-box" type="text" wire:model="village_city_name" placeholder="City or Village Name / शहर या गाँव का नाम" />
                <?php $__errorArgs = ['village_city_name'];
$__bag = $errors->getBag($__errorArgs[1] ?? 'default');
if ($__bag->has($__errorArgs[0])) :
if (isset($message)) { $__messageOriginal = $message; }
$message = $__bag->first($__errorArgs[0]); ?> <span class="error"><?php echo e($message); ?></span> <?php unset($message);
if (isset($__messageOriginal)) { $message = $__messageOriginal; }
endif;
unset($__errorArgs, $__bag); ?>

                <!-- <input type="text" placeholder="District / जिला" class="input-box"> -->
                <!-- <input type="text" placeholder="Assembly / विधानसभा" class="input-box"> -->
                <!-- <input type="text" placeholder="City or Village Name / शहर या गाँव का नाम" class="input-box"> -->
                <button value="buttonn" class="submit-button" wire:click="saveUser">Submit</button>
            </div>
        <?php endif; ?>
    </div>
</div>
<?php /**PATH /home/raktveerco/public_html/resources/views/livewire/authentication.blade.php ENDPATH**/ ?>