<div class="panel"> 
    <div class="panel-body">
        <form role="form" class="form-horizontal" action="<?= base_url('house_submit'); ?>" method="POST">
            <h2 class="text-center">House Registration Form</h2>  
            <hr class="colorgraph">
            <div class="row">
                <div class="col-md-6 col-md-push-2">
                    <div class="form-group">
                        <div class="input-group">
                            <span class="input-group-addon"><strong>House Head Name</strong></span>
                            <input class="form-control" required name="full_name"type="text" placeholder="House Head Full Name">

                        </div>                    
                    </div>
                </div>
            </div>           
            <div class="row">
                <div class="col-md-4 col-md-push-2">
                    <div class="form-group"> 
                        <div class="input-group">
                            <span class="input-group-addon"><strong>House Number</strong></span>
                            <input class="form-control" type="text" required name="house_number" value="H"placeholder="House Number">
                        </div>                    
                    </div> 
                </div>
                <div class="col-md-4 col-md-push-2" style="margin-left: 10px">
                    <div class="form-group"> 
                        <div class="input-group">
                            <span class="input-group-addon"><strong>Total Family Member</strong></span>
                            <input class="form-control" type="number" required name="total_family" placeholder="Please eneter number">
                        </div>                    
                    </div> 
                </div>
            </div>
            <div class="row">
                <div class="col-md-4 col-md-push-2">
                    <div class="form-group"> 
                        <div class="input-group">
                            <span class="input-group-addon"><strong>Married Women</strong></span>
                            <input class="form-control" type="number" required name="married_women" placeholder="please enter number">
                        </div>                    
                    </div> 
                </div>
                <div class="col-md-4 col-md-push-2" style="margin-left: 10px">
                    <div class="form-group"> 
                        <div class="input-group">
                            <span class="input-group-addon"><strong>Unmarried Women</strong></span>
                            <input class="form-control" type="number" required name="unmarried_women" placeholder="Please enter number">
                        </div>                    
                    </div> 
                </div>
            </div>
            <div class="row">
                <div class="col-md-4 col-md-push-2">
                    <div class="form-group"> 
                        <div class="input-group">
                            <span class="input-group-addon"><strong>Adolescence Girl</strong></span>
                            <input class="form-control" type="number" required name="adolescence" placeholder="Please enter number">
                        </div>                    
                    </div> 
                </div>
                <div class="col-md-4 col-md-push-2" style="margin-left: 10px">
                    <div class="form-group"> 
                        <div class="input-group">
                            <span class="input-group-addon"><strong>Child</strong></span>
                            <input class="form-control" type="number" required name="child" placeholder="Please enter number">
                        </div>                    
                    </div> 
                </div>
            </div>
            <div class="row">
                <div class="col-md-8 col-md-offset-2 col-sm-10 col-sm-offset-1">
                    <?php $this->load->view('mira_alert_message'); ?>
                </div>
            </div>
            <hr class="colorgraph">
            <div class="row">
                <div class="col-xs-8 col-md-4 col-md-offset-4 col-xs-offset-2"><input type="submit" value="House Registration" class="btn btn-primary btn-lg btn-block"></div>            
            </div>
        </form>
    </div>
</div>

