@extends('header_nuevo_generico')
@section('main')
<script type="text/javascript" src="//js.jotform.com/JotFormAnywhere.js"></script>
<div class="container-fluid mt-5 pt-5">
    <button onclick="JotformAnywhere.launchFormBuilder({formId:'{{$data[0]->id}}'});">Add Form</button>
</div>
<div id="builder"></div>
<form action="" method="post">
    {{ csrf_field() }}
    <textarea name="" id=""></textarea>
</form>
<!-- <script src="https://cdn02.jotfor.ms/static/prototype.forms.js?v=3.3.55907" type="text/javascript"></script> -->
<!-- <script src="https://cdn03.jotfor.ms/static/jotform.forms.js?v=3.3.55907" type="text/javascript"></script> -->
<!-- <script src="https://cdn01.jotfor.ms/js/punycode-1.4.1.min.js?v=3.3.55907" type="text/javascript" defer></script> -->
<!-- <script src="https://cdn02.jotfor.ms/js/vendor/maskedinput_5.0.9.min.js?v=3.3.55907" type="text/javascript"></script> -->
<!-- <script src="https://cdn01.jotfor.ms/s/umd/7d93e821146/for-form-branding-footer.js?v=3.3.55907" type="text/javascript" defer></script> -->
<!-- <script src="https://cdn03.jotfor.ms/js/vendor/smoothscroll.min.js?v=3.3.55907" type="text/javascript"></script> -->
<!-- <script src="https://cdn01.jotfor.ms/js/errorNavigation.js?v=3.3.55907" type="text/javascript"></script> -->
<script type="text/javascript">	JotForm.newDefaultTheme = true;
    JotForm.extendsNewTheme = false;
    JotForm.singleProduct = false;
    JotForm.newPaymentUIForNewCreatedForms = false;
    JotForm.texts = { "confirmEmail": "E-mail does not match", "pleaseWait": "Please wait...", "validateEmail": "You need to validate this e-mail", "confirmClearForm": "Are you sure you want to clear the form", "lessThan": "Your score should be less than or equal to", "incompleteFields": "There are incomplete required fields. Please complete them.", "required": "This field is required.", "requireOne": "At least one field required.", "requireEveryRow": "Every row is required.", "requireEveryCell": "Every cell is required.", "email": "Enter a valid e-mail address", "alphabetic": "This field can only contain letters", "numeric": "This field can only contain numeric values", "alphanumeric": "This field can only contain letters and numbers.", "cyrillic": "This field can only contain cyrillic characters", "url": "This field can only contain a valid URL", "currency": "This field can only contain currency values.", "fillMask": "Field value must fill mask.", "uploadExtensions": "You can only upload following files:", "noUploadExtensions": "File has no extension file type (e.g. .txt, .png, .jpeg)", "uploadFilesize": "File size cannot be bigger than:", "uploadFilesizemin": "File size cannot be smaller than:", "gradingScoreError": "Score total should only be less than or equal to", "inputCarretErrorA": "Input should not be less than the minimum value:", "inputCarretErrorB": "Input should not be greater than the maximum value:", "maxDigitsError": "The maximum digits allowed is", "minCharactersError": "The number of characters should not be less than the minimum value:", "maxCharactersError": "The number of characters should not be more than the maximum value:", "freeEmailError": "Free email accounts are not allowed", "minSelectionsError": "The minimum required number of selections is ", "maxSelectionsError": "The maximum number of selections allowed is ", "pastDatesDisallowed": "Date must not be in the past.", "dateLimited": "This date is unavailable.", "dateInvalid": "This date is not valid. The date format is {format}", "dateInvalidSeparate": "This date is not valid. Enter a valid {element}.", "ageVerificationError": "You must be older than {minAge} years old to submit this form.", "multipleFileUploads_typeError": "{file} has invalid extension. Only {extensions} are allowed.", "multipleFileUploads_sizeError": "{file} is too large, maximum file size is {sizeLimit}.", "multipleFileUploads_minSizeError": "{file} is too small, minimum file size is {minSizeLimit}.", "multipleFileUploads_emptyError": "{file} is empty, please select files again without it.", "multipleFileUploads_uploadFailed": "File upload failed, please remove it and upload the file again.", "multipleFileUploads_onLeave": "The files are being uploaded, if you leave now the upload will be cancelled.", "multipleFileUploads_fileLimitError": "Only {fileLimit} file uploads allowed.", "dragAndDropFilesHere_infoMessage": "Drag and drop files here", "chooseAFile_infoMessage": "Choose a file", "maxFileSize_infoMessage": "Max. file size", "generalError": "There are errors on the form. Please fix them before continuing.", "generalPageError": "There are errors on this page. Please fix them before continuing.", "wordLimitError": "Too many words. The limit is", "wordMinLimitError": "Too few words.  The minimum is", "characterLimitError": "Too many Characters.  The limit is", "characterMinLimitError": "Too few characters. The minimum is", "ccInvalidNumber": "Credit Card Number is invalid.", "ccInvalidCVC": "CVC number is invalid.", "ccInvalidExpireDate": "Expire date is invalid.", "ccInvalidExpireMonth": "Expiration month is invalid.", "ccInvalidExpireYear": "Expiration year is invalid.", "ccMissingDetails": "Please fill up the credit card details.", "ccMissingProduct": "Please select at least one product.", "ccMissingDonation": "Please enter numeric values for donation amount.", "disallowDecimals": "Please enter a whole number.", "restrictedDomain": "This domain is not allowed", "ccDonationMinLimitError": "Minimum amount is {minAmount} {currency}", "requiredLegend": "All fields marked with * are required and must be filled.", "geoPermissionTitle": "Permission Denied", "geoPermissionDesc": "Check your browser's privacy settings.", "geoNotAvailableTitle": "Position Unavailable", "geoNotAvailableDesc": "Location provider not available. Please enter the address manually.", "geoTimeoutTitle": "Timeout", "geoTimeoutDesc": "Please check your internet connection and try again.", "selectedTime": "Selected Time", "formerSelectedTime": "Former Time", "cancelAppointment": "Cancel Appointment", "cancelSelection": "Cancel Selection", "noSlotsAvailable": "No slots available", "slotUnavailable": "{time} on {date} has been selected is unavailable. Please select another slot.", "multipleError": "There are {count} errors on this page. Please correct them before moving on.", "oneError": "There is {count} error on this page. Please correct it before moving on.", "doneMessage": "Well done! All errors are fixed.", "invalidTime": "Enter a valid time", "doneButton": "Done", "reviewSubmitText": "Review and Submit", "nextButtonText": "Next", "prevButtonText": "Previous", "seeErrorsButton": "See Errors", "notEnoughStock": "Not enough stock for the current selection", "notEnoughStock_remainedItems": "Not enough stock for the current selection ({count} items left)", "soldOut": "Sold Out", "justSoldOut": "Just Sold Out", "selectionSoldOut": "Selection Sold Out", "subProductItemsLeft": "({count} items left)", "startButtonText": "START", "submitButtonText": "Submit", "submissionLimit": "Sorry! Only one entry is allowed. <br> Multiple submissions are disabled for this form.", "reviewBackText": "Back to Form", "seeAllText": "See All", "progressMiddleText": "of", "fieldError": "field has an error.", "error": "Error" };
    JotForm.newPaymentUI = true;
    JotForm.originalLanguage = "en";
    JotForm.replaceTagTest = true;
    JotForm.submitError = "jumpToFirstError";
    window.addEventListener('DOMContentLoaded', function () { window.brandingFooter.init({ "formID": 242203733431647, "campaign": "powered_by_jotform_le", "isCardForm": false, "isLegacyForm": true, "formLanguage": "en" }) }); JotForm.isFullSource = true;

    JotForm.init(function () {
        /*INIT-START*/
        JotForm.setPhoneMaskingValidator('input_27_full', '\u0028\u0023\u0023\u0023\u0029 \u0023\u0023\u0023\u002d\u0023\u0023\u0023\u0023');
        JotForm.setPhoneMaskingValidator('input_25_full', '\u0028\u0023\u0023\u0023\u0029 \u0023\u0023\u0023\u002d\u0023\u0023\u0023\u0023');
        JotForm.setPhoneMaskingValidator('input_26_full', '\u0028\u0023\u0023\u0023\u0029 \u0023\u0023\u0023\u002d\u0023\u0023\u0023\u0023');
        if (window.JotForm && JotForm.accessible) $('input_14').setAttribute('tabindex', 0);
        if (window.JotForm && JotForm.accessible) $('input_45').setAttribute('tabindex', 0);
        /*INIT-END*/
    });

    setTimeout(function () {
        JotForm.paymentExtrasOnTheFly([null, { "name": "clickTo", "qid": "1", "text": "Registration Form", "type": "control_head" }, null, { "name": "gender", "qid": "3", "text": "Gender", "type": "control_dropdown" }, { "name": "studentName", "qid": "4", "text": "Student Name", "type": "control_fullname" }, null, { "name": "studentEmail6", "qid": "6", "subLabel": "example@example.com", "text": "Student E-mail", "type": "control_email" }, null, null, null, null, null, null, null, { "name": "company", "qid": "14", "text": "Company", "type": "control_textbox" }, null, null, null, null, null, null, null, null, { "name": "address", "qid": "23", "text": "Address", "type": "control_address" }, { "name": "birthDate24", "qid": "24", "text": "Birth Date", "type": "control_birthdate" }, { "name": "phoneNumber25", "qid": "25", "text": "Phone Number", "type": "control_phone" }, { "name": "workNumber", "qid": "26", "text": "Work Number", "type": "control_phone" }, { "name": "mobileNumber", "qid": "27", "text": "Mobile Number", "type": "control_phone" }, null, null, null, null, null, null, null, null, null, null, null, null, null, null, null, null, null, { "mde": "No", "name": "clickTo45", "qid": "45", "text": "Additional Comments", "type": "control_textarea", "wysiwyg": "Disable" }, { "name": "courses", "qid": "46", "text": "Courses", "type": "control_dropdown" }, null, null, null, null, null, { "name": "submit", "qid": "52", "text": "Submit", "type": "control_button" }]);
    }, 20); 
</script>
<style>
    .app.isBuilder .form-all {
        margin: 0 auto 20px !important
    }

    .formPage-container .formPage-each:not(:first-of-type) .form-all:before {
        display: none
    }

    .form-cover-wrapper+.form-all {
        margin-top: 0
    }

    .form-cover-wrapper+.form-all:before {
        content: none
    }

    .form-cover-wrapper {
        margin: 0 auto 32px;
        padding-top: 32px;
        position: relative;
        overflow: hidden;
        transition: all .33s ease
    }

    .form-cover-wrapper.form-page-cover-image-align-left .form-page-cover-image-wrapper {
        -ms-flex-pack: start;
        justify-content: flex-start
    }

    .form-cover-wrapper.form-page-cover-image-align-center .form-page-cover-image-wrapper {
        -ms-flex-pack: center;
        justify-content: center
    }

    .form-cover-wrapper.form-page-cover-image-align-right .form-page-cover-image-wrapper {
        -ms-flex-pack: end;
        justify-content: flex-end
    }

    .form-cover-wrapper .form-page-cover-text {
        line-height: 50px
    }

    .form-cover-wrapper .add-form-logo {
        display: -ms-flexbox;
        display: flex;
        background-repeat: no-repeat;
        border: 0;
        background-color: transparent;
        padding-block: 0;
        padding-inline: 0
    }

    .form-page-cover-image-wrapper {
        width: 100%;
        margin: 0 auto;
        display: -ms-flexbox;
        display: flex;
        -ms-flex-pack: center;
        justify-content: center
    }

    .form-page-cover-uploader {
        cursor: pointer;
        min-height: 60px;
        border: 2px dashed #499fff;
        color: #499fff;
        text-align: center;
        display: table;
        margin: auto auto 10px;
        width: 100%;
        font-size: 18px;
        border-radius: 4px;
        font-weight: 400;
        padding: 15px;
        transition: all .33s ease
    }

    .form-page-cover-uploader:hover {
        background-color: rgba(73, 159, 255, .11);
        transition: all .33s ease
    }

    .form-page-cover-uploader .form-page-cover-icon,
    .form-page-cover-uploader .form-page-cover-text {
        display: -ms-inline-flexbox;
        display: inline-flex;
        vertical-align: middle;
        margin: auto 12px auto auto
    }

    .hasFormUserAvatar .form-cover-wrapper {
        margin-top: 70px
    }

    .hasFormUserAvatar .form-cover-wrapper+.form-all {
        top: revert
    }

    .forEditSubmissionAlert {
        position: fixed;
        -ms-flex-pack: center;
        justify-content: center;
        top: 0;
        left: 0;
        background-color: rgba(0, 0, 0, .3);
        color: #000;
        width: 100%;
        height: 100%;
        z-index: 9;
        font-family: Inter, sans-serif
    }

    .forEditSubmissionAlert,
    .forEditSubmissionAlert .modal-inner {
        display: -ms-flexbox;
        display: flex;
        -ms-flex-align: center;
        align-items: center
    }

    .forEditSubmissionAlert .modal-inner {
        width: 480px;
        background: #fff;
        padding: 32px;
        border-radius: 4px;
        -ms-flex-direction: column;
        flex-direction: column;
        text-align: center;
        max-width: 80%
    }

    .forEditSubmissionAlert .warning-header {
        color: #0a1551;
        font-size: 18px;
        font-weight: 500;
        line-height: 28px;
        margin-top: 24px
    }

    .forEditSubmissionAlert .warning-message {
        color: #6f76a7;
        font-size: 14px;
        font-weight: 400;
        line-height: 20px;
        margin-top: 8px
    }

    .forEditSubmissionAlert .warning-cta {
        display: -ms-flexbox;
        display: flex;
        -ms-flex-direction: row-reverse;
        flex-direction: row-reverse;
        -ms-flex-align: center;
        align-items: center;
        -ms-flex-pack: justify;
        justify-content: space-between;
        width: 100%;
        margin-top: 32px
    }

    .forEditSubmissionAlert .warning-cta .forRefresh {
        background: #0075e3;
        padding: 10px 12px;
        margin: 0;
        color: #fff;
        border-radius: 4px;
        font-size: 14px;
        font-weight: 500;
        cursor: pointer
    }

    .forEditSubmissionAlert .warning-cta .forRefresh:hover {
        background-color: #0066c3
    }

    .forEditSubmissionAlert .warning-cta .forCreate {
        font-weight: 600;
        color: #0075e3;
        font-size: 14px;
        cursor: pointer
    }

    .forEditSubmissionAlert .warning-cta .forCreate:hover {
        color: #0066c3
    }
</style>
<!-- <link type="text/css" rel="stylesheet" href="https://cdn01.jotfor.ms/stylebuilder/static/form-common.css?v=80facca -->
<!-- "/> -->
<style type="text/css">
    @media print {
        * {
            -webkit-print-color-adjust: exact !important;
            color-adjust: exact !important;
        }

        .form-section {
            display: inline !important
        }

        .form-pagebreak {
            display: none !important
        }

        .form-section-closed {
            height: auto !important
        }

        .page-section {
            position: initial !important
        }
    }
</style>
<link type="text/css" rel="stylesheet"
    href="https://cdn02.jotfor.ms/themes/CSS/5e6b428acc8c4e222d1beb91.css?v=3.3.55907&themeRevisionID=65660e4b326633110492e01a" />
<link type="text/css" rel="stylesheet" href="https://cdn03.jotfor.ms/css/styles/payment/payment_styles.css?3.3.55907" />
<link type="text/css" rel="stylesheet"
    href="https://cdn01.jotfor.ms/css/styles/payment/payment_feature.css?3.3.55907" />
<form class="jotform-form" onsubmit="return typeof testSubmitFunction !== 'undefined' && testSubmitFunction();"
    action="https://submit.jotform.com/submit/242203733431647" method="post" name="form_242203733431647"
    id="242203733431647" accept-charset="utf-8" autocomplete="on"><input type="hidden" name="formID"
        value="242203733431647" /><input type="hidden" id="JWTContainer" value="" /><input type="hidden"
        id="cardinalOrderNumber" value="" /><input type="hidden" id="jsExecutionTracker" name="jsExecutionTracker"
        value="build-date-1723119753584" /><input type="hidden" id="submitSource" name="submitSource"
        value="unknown" /><input type="hidden" id="buildDate" name="buildDate" value="1723119753584" />
    <div role="main" class="form-all">
        <ul class="form-section page-section">
            <li id="cid_1" class="form-input-wide" data-type="control_head">
                <div class="form-header-group  header-large">
                    <div class="header-text httal htvam">
                        <h1 id="header_1" class="form-header" data-component="header">Registration Form</h1>
                        <div id="subHeader_1" class="form-subHeader">Fill out the form carefully for registration</div>
                    </div>
                </div>
            </li>
            <li class="form-line" data-type="control_fullname" id="id_4"><label
                    class="form-label form-label-top form-label-extended form-label-auto" id="label_4" for="first_4"
                    aria-hidden="false"> Student Name </label>
                <div id="cid_4" class="form-input-wide" data-layout="full">
                    <div data-wrapper-react="true" class="extended"><span class="form-sub-label-container"
                            style="vertical-align:top" data-input-type="first"><input type="text" id="first_4"
                                name="q4_studentName[first]" class="form-textbox" data-defaultvalue=""
                                autoComplete="section-input_4 given-name" size="10" data-component="first"
                                aria-labelledby="label_4 sublabel_4_first" value="" /><label class="form-sub-label"
                                for="first_4" id="sublabel_4_first" style="min-height:13px">First
                                Name</label></span><span class="form-sub-label-container" style="vertical-align:top"
                            data-input-type="middle"><input type="text" id="middle_4" name="q4_studentName[middle]"
                                class="form-textbox" data-defaultvalue="" autoComplete="section-input_4 additional-name"
                                size="10" data-component="middle" aria-labelledby="label_4 sublabel_4_middle"
                                value="" /><label class="form-sub-label" for="middle_4" id="sublabel_4_middle"
                                style="min-height:13px">Middle Name</label></span><span class="form-sub-label-container"
                            style="vertical-align:top" data-input-type="last"><input type="text" id="last_4"
                                name="q4_studentName[last]" class="form-textbox" data-defaultvalue=""
                                autoComplete="section-input_4 family-name" size="15" data-component="last"
                                aria-labelledby="label_4 sublabel_4_last" value="" /><label class="form-sub-label"
                                for="last_4" id="sublabel_4_last" style="min-height:13px">Last Name</label></span></div>
                </div>
            </li>
            <li class="form-line form-line-column form-col-1" data-type="control_birthdate" id="id_24"><label
                    class="form-label form-label-top" id="label_24" for="input_24" aria-hidden="false"> Birth Date
                </label>
                <div id="cid_24" class="form-input-wide" data-layout="full">
                    <div data-wrapper-react="true"><span class="form-sub-label-container"
                            style="vertical-align:top"><select name="q24_birthDate24[month]" id="input_24_month"
                                class="form-dropdown" data-component="birthdate-month"
                                aria-labelledby="label_24 sublabel_24_month">
                                <option value="">Please select a month</option>
                                <option value="1">January</option>
                                <option value="2">February</option>
                                <option value="3">March</option>
                                <option value="4">April</option>
                                <option value="5">May</option>
                                <option value="6">June</option>
                                <option value="7">July</option>
                                <option value="8">August</option>
                                <option value="9">September</option>
                                <option value="10">October</option>
                                <option value="11">November</option>
                                <option value="12">December</option>
                            </select><label class="form-sub-label" for="input_24_month" id="sublabel_24_month"
                                style="min-height:13px">Month</label></span><span class="form-sub-label-container"
                            style="vertical-align:top"><select name="q24_birthDate24[day]" id="input_24_day"
                                class="form-dropdown" data-component="birthdate-day"
                                aria-labelledby="label_24 sublabel_24_day">
                                <option value="">Please select a 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><label class="form-sub-label" for="input_24_day" id="sublabel_24_day"
                                style="min-height:13px">Day</label></span><span class="form-sub-label-container"
                            style="vertical-align:top"><select name="q24_birthDate24[year]" id="input_24_year"
                                class="form-dropdown" data-component="birthdate-year"
                                aria-labelledby="label_24 sublabel_24_year">
                                <option value="">Please select a year</option>
                                <option value="2024">2024</option>
                                <option value="2023">2023</option>
                                <option value="2022">2022</option>
                                <option value="2021">2021</option>
                                <option value="2020">2020</option>
                                <option value="2019">2019</option>
                                <option value="2018">2018</option>
                                <option value="2017">2017</option>
                                <option value="2016">2016</option>
                                <option value="2015">2015</option>
                                <option value="2014">2014</option>
                                <option value="2013">2013</option>
                                <option value="2012">2012</option>
                                <option value="2011">2011</option>
                                <option value="2010">2010</option>
                                <option value="2009">2009</option>
                                <option value="2008">2008</option>
                                <option value="2007">2007</option>
                                <option value="2006">2006</option>
                                <option value="2005">2005</option>
                                <option value="2004">2004</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>
                            </select><label class="form-sub-label" for="input_24_year" id="sublabel_24_year"
                                style="min-height:13px">Year</label></span></div>
                </div>
            </li>
            <li class="form-line form-line-column form-col-2" data-type="control_dropdown" id="id_3"><label
                    class="form-label form-label-top" id="label_3" for="input_3" aria-hidden="false"> Gender </label>
                <div id="cid_3" class="form-input-wide" data-layout="half"> <select class="form-dropdown" id="input_3"
                        name="q3_gender" style="width:310px" data-component="dropdown" aria-label="Gender">
                        <option value="">Please Select</option>
                        <option value="Male">Male</option>
                        <option value="Female">Female</option>
                        <option value="N/A">N/A</option>
                    </select> </div>
            </li>
            <li class="form-line" data-type="control_address" id="id_23"><label
                    class="form-label form-label-top form-label-auto" id="label_23" for="input_23_addr_line1"
                    aria-hidden="false"> Address </label>
                <div id="cid_23" class="form-input-wide" data-layout="full">
                    <div summary="" class="form-address-table jsTest-addressField">
                        <div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span
                                class="form-address-line form-address-street-line jsTest-address-lineField"><span
                                    class="form-sub-label-container" style="vertical-align:top"><input type="text"
                                        id="input_23_addr_line1" name="q23_address[addr_line1]"
                                        class="form-textbox form-address-line" data-defaultvalue=""
                                        autoComplete="section-input_23 address-line1" data-component="address_line_1"
                                        aria-labelledby="label_23 sublabel_23_addr_line1" value="" /><label
                                        class="form-sub-label" for="input_23_addr_line1" id="sublabel_23_addr_line1"
                                        style="min-height:13px">Street Address</label></span></span></div>
                        <div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span
                                class="form-address-line form-address-street-line jsTest-address-lineField"><span
                                    class="form-sub-label-container" style="vertical-align:top"><input type="text"
                                        id="input_23_addr_line2" name="q23_address[addr_line2]"
                                        class="form-textbox form-address-line" data-defaultvalue=""
                                        autoComplete="section-input_23 address-line2" data-component="address_line_2"
                                        aria-labelledby="label_23 sublabel_23_addr_line2" value="" /><label
                                        class="form-sub-label" for="input_23_addr_line2" id="sublabel_23_addr_line2"
                                        style="min-height:13px">Street Address Line 2</label></span></span></div>
                        <div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span
                                class="form-address-line form-address-city-line jsTest-address-lineField "><span
                                    class="form-sub-label-container" style="vertical-align:top"><input type="text"
                                        id="input_23_city" name="q23_address[city]"
                                        class="form-textbox form-address-city" data-defaultvalue=""
                                        autoComplete="section-input_23 address-level2" data-component="city"
                                        aria-labelledby="label_23 sublabel_23_city" value="" /><label
                                        class="form-sub-label" for="input_23_city" id="sublabel_23_city"
                                        style="min-height:13px">City</label></span></span><span
                                class="form-address-line form-address-state-line jsTest-address-lineField "><span
                                    class="form-sub-label-container" style="vertical-align:top"><input type="text"
                                        id="input_23_state" name="q23_address[state]"
                                        class="form-textbox form-address-state" data-defaultvalue=""
                                        autoComplete="section-input_23 address-level1" data-component="state"
                                        aria-labelledby="label_23 sublabel_23_state" value="" /><label
                                        class="form-sub-label" for="input_23_state" id="sublabel_23_state"
                                        style="min-height:13px">State / Province</label></span></span></div>
                        <div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span
                                class="form-address-line form-address-zip-line jsTest-address-lineField "><span
                                    class="form-sub-label-container" style="vertical-align:top"><input type="text"
                                        id="input_23_postal" name="q23_address[postal]"
                                        class="form-textbox form-address-postal" data-defaultvalue=""
                                        autoComplete="section-input_23 postal-code" data-component="zip"
                                        aria-labelledby="label_23 sublabel_23_postal" value="" /><label
                                        class="form-sub-label" for="input_23_postal" id="sublabel_23_postal"
                                        style="min-height:13px">Postal / Zip Code</label></span></span></div>
                    </div>
                </div>
            </li>
            <li class="form-line form-line-column form-col-1" data-type="control_email" id="id_6"><label
                    class="form-label form-label-top" id="label_6" for="input_6" aria-hidden="false"> Student E-mail
                </label>
                <div id="cid_6" class="form-input-wide" data-layout="half"> <span class="form-sub-label-container"
                        style="vertical-align:top"><input type="email" id="input_6" name="q6_studentEmail6"
                            class="form-textbox validate[Email]" data-defaultvalue=""
                            autoComplete="section-input_6 email" style="width:310px" size="310"
                            placeholder="ex: myname@example.com" data-component="email"
                            aria-labelledby="label_6 sublabel_input_6" value="" /><label class="form-sub-label"
                            for="input_6" id="sublabel_input_6"
                            style="min-height:13px">example@example.com</label></span> </div>
            </li>
            <li class="form-line form-line-column form-col-2" data-type="control_phone" id="id_27"><label
                    class="form-label form-label-top" id="label_27" for="input_27_full"> Mobile Number </label>
                <div id="cid_27" class="form-input-wide" data-layout="half"> <span class="form-sub-label-container"
                        style="vertical-align:top"><input type="tel" id="input_27_full" name="q27_mobileNumber[full]"
                            data-type="mask-number" class="mask-phone-number form-textbox validate[Fill Mask]"
                            data-defaultvalue="" autoComplete="section-input_27 tel-national" style="width:310px"
                            data-masked="true" placeholder="(000) 000-0000" data-component="phone"
                            aria-labelledby="label_27" value="" /></span> </div>
            </li>
            <li class="form-line form-line-column form-col-3" data-type="control_phone" id="id_25"><label
                    class="form-label form-label-top" id="label_25" for="input_25_full"> Phone Number </label>
                <div id="cid_25" class="form-input-wide" data-layout="half"> <span class="form-sub-label-container"
                        style="vertical-align:top"><input type="tel" id="input_25_full" name="q25_phoneNumber25[full]"
                            data-type="mask-number" class="mask-phone-number form-textbox validate[Fill Mask]"
                            data-defaultvalue="" autoComplete="section-input_25 tel-national" style="width:310px"
                            data-masked="true" placeholder="(000) 000-0000" data-component="phone"
                            aria-labelledby="label_25" value="" /></span> </div>
            </li>
            <li class="form-line form-line-column form-col-4" data-type="control_phone" id="id_26"><label
                    class="form-label form-label-top" id="label_26" for="input_26_full"> Work Number </label>
                <div id="cid_26" class="form-input-wide" data-layout="half"> <span class="form-sub-label-container"
                        style="vertical-align:top"><input type="tel" id="input_26_full" name="q26_workNumber[full]"
                            data-type="mask-number" class="mask-phone-number form-textbox validate[Fill Mask]"
                            data-defaultvalue="" autoComplete="section-input_26 tel-national" style="width:310px"
                            data-masked="true" placeholder="(000) 000-0000" data-component="phone"
                            aria-labelledby="label_26" value="" /></span> </div>
            </li>
            <li class="form-line form-line-column form-col-5" data-type="control_textbox" id="id_14"><label
                    class="form-label form-label-top" id="label_14" for="input_14" aria-hidden="false"> Company </label>
                <div id="cid_14" class="form-input-wide" data-layout="half"> <input type="text" id="input_14"
                        name="q14_company" data-type="input-textbox" class="form-textbox" data-defaultvalue=""
                        style="width:310px" size="310" placeholder=" " data-component="textbox"
                        aria-labelledby="label_14" value="" /> </div>
            </li>
            <li class="form-line form-line-column form-col-6" data-type="control_dropdown" id="id_46"><label
                    class="form-label form-label-top" id="label_46" for="input_46" aria-hidden="false"> Courses </label>
                <div id="cid_46" class="form-input-wide" data-layout="half"> <select class="form-dropdown" id="input_46"
                        name="q46_courses" style="width:310px" data-component="dropdown" aria-label="Courses">
                        <option value="">Please Select</option>
                        <option value="Windows 8">Windows 8</option>
                        <option value="Introduction to Linux">Introduction to Linux</option>
                        <option value="English 101">English 101</option>
                        <option value="English 102">English 102</option>
                        <option value="Creative Writing 1">Creative Writing 1</option>
                        <option value="Creative writing 2">Creative writing 2</option>
                        <option value="History 101">History 101</option>
                        <option value="History 102">History 102</option>
                        <option value="Math 101">Math 101</option>
                        <option value="Math 102">Math 102</option>
                    </select> </div>
            </li>
            <li class="form-line" data-type="control_textarea" id="id_45"><label
                    class="form-label form-label-top form-label-auto" id="label_45" for="input_45" aria-hidden="false">
                    Additional Comments </label>
                <div id="cid_45" class="form-input-wide" data-layout="full"> <textarea id="input_45"
                        class="form-textarea" name="q45_clickTo45" style="width:648px;height:163px"
                        data-component="textarea" aria-labelledby="label_45"></textarea> </div>
            </li>
            <li class="form-line" data-type="control_button" id="id_52">
                <div id="cid_52" class="form-input-wide" data-layout="full">
                    <div data-align="auto" class="form-buttons-wrapper form-buttons-auto   jsTest-button-wrapperField">
                        <button id="input_52" type="submit"
                            class="form-submit-button submit-button jf-form-buttons jsTest-submitField"
                            data-component="button" data-content="">Submit</button></div>
                </div>
            </li>
            <li style="clear:both"></li>
            <li style="display:none">Should be Empty: <input type="text" name="website" value="" type="hidden" /></li>
        </ul>
    </div>
    <script>
        JotForm.showJotFormPowered = "new_footer";
    </script>
    <script>
        JotForm.poweredByText = "Powered by Jotform";
    </script><input type="hidden" class="simple_spc" id="simple_spc" name="simple_spc" value="242203733431647" />
    <script type="text/javascript">
        var all_spc = document.querySelectorAll("form[id='242203733431647'] .si" + "mple" + "_spc");
        for (var i = 0; i < all_spc.length; i++) {
            all_spc[i].value = "242203733431647-242203733431647";
        }
    </script>
</form>
<script type="text/javascript">JotForm.ownerView = true;</script>
<script type="text/javascript">JotForm.isNewSACL = true;</script>
@endsection
@section('funcionesJS')
<script src="{{ asset('/Libreria_CA/Js/funciones_imperium_paneles.js') }}?v={{rand()}}"></script>
<script>
    $(document).on('change', '#formTemplatesFrame', function () {
        console.log('aca');
    })
</script>
@endsection