s

 

 

 

<div class=”header”>
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html>
<html lang=”ro”>
<head>
<meta charset=”UTF-8″>
<meta name=”viewport” content=”width=device-width, initial-scale=1.0″>
<title>Retreat pentru Cupluri – Înscriere</title>
<style>
* {
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input[type=”text”],
input[type=”email”],
input[type=”tel”],
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</style>
</head>
<body>
<div class=”container”>
<div class=”header”>
<h1>BISERICA BETLEEM MEDGIDIA organizează</h1>
<p><span class=”heart-icon”>♥</span> Retreat pentru cupluri cu două familii menonite din SUA <span class=”heart-icon”>♥</span></p>
</div>

<div class=”form-container”>
<form id=”coupleForm”>
<div class=”section-title”>Informații Cuplu</div>

<div class=”form-row”>
<div class=”form-group”>
<label for=”nume_barbat”>Numele soțului *</label>
<input type=”text” id=”nume_barbat” name=”nume_barbat” required>
</div>
<div class=”form-group”>
<label for=”nume_sotie”>Numele soției *</label>
<input type=”text” id=”nume_sotie” name=”nume_sotie” required>
</div>
</div>

<div class=”form-row”>
<div class=”form-group”>
<label for=”varsta_barbat”>Vârsta soțului *</label>
<input type=”number” id=”varsta_barbat” name=”varsta_barbat” min=”18″ max=”100″ required>
</div>
<div class=”form-group”>
<label for=”varsta_sotie”>Vârsta soției *</label>
<input type=”number” id=”varsta_sotie” name=”varsta_sotie” min=”18″ max=”100″ required>
</div>
</div>

<div class=”form-group”>
<label for=”email”>Email *</label>
<input type=”email” id=”email” name=”email” required>
</div>

<div class=”form-group”>
<label for=”telefon”>Număr de telefon *</label>
<input type=”tel” id=”telefon” name=”telefon” required>
</div>

<div class=”form-group”>
<label for=”oras”>Orașul *</label>
<input type=”text” id=”oras” name=”oras” required>
</div>

<div class=”form-group”>
<label for=”biserica”>Biserica în care sunteți membri *</label>
<input type=”text” id=”biserica” name=”biserica” required>
</div>

<div class=”form-group”>
<label for=”ani_casatorie”>Câți ani sunteți căsătoriți? *</label>
<input type=”number” id=”ani_casatorie” name=”ani_casatorie” min=”0″ max=”70″ required>
</div>

<div class=”form-group”>
<label for=”copii”>Aveți copii? Dacă da, vârstele lor:</label>
<textarea id=”copii” name=”copii” placeholder=”Ex: Da, 8 ani și 12 ani sau Nu”></textarea>
</div>

<div class=”section-title”>Contribuție financiară</div>

<div class=”form-group”>
<label>Cu ce sumă puteți contribui? *</label>
<div class=”contribution-options”>
<div class=”radio-item”>
<input type=”radio” id=”contrib_200″ name=”contributie” value=”200″ required>
<label for=”contrib_200″>200 lei</label>
</div>
<div class=”radio-item”>
<input type=”radio” id=”contrib_300″ name=”contributie” value=”300″ required>
<label for=”contrib_300″>300 lei</label>
</div>
<div class=”radio-item”>
<input type=”radio” id=”contrib_400″ name=”contributie” value=”400″ required>
<label for=”contrib_400″>400 lei</label>
</div>
<div class=”radio-item”>
<input type=”radio” id=”contrib_500″ name=”contributie” value=”500″ required>
<label for=”contrib_500″>500 lei</label>
</div>
<div class=”radio-item”>
<input type=”radio” id=”contrib_alta” name=”contributie” value=”alta” required>
<label for=”contrib_alta”>altă sumă</label>
</div>
</div>
<div class=”custom-amount” id=”custom_amount_field”>
<label for=”suma_personalizata”>Specificați suma (lei):</label>
<input type=”number” id=”suma_personalizata” name=”suma_personalizata” min=”200″ placeholder=”Introduceți suma în lei”>
</div>
</div>

<div class=”section-title”>Participări anterioare</div>

<div class=”form-group”>
<label>Ați mai participat la evenimente similare?</label>
<div class=”checkbox-group”>
<div class=”checkbox-item”>
<input type=”checkbox” id=”retreat_anterior” name=”participari_anterioare” value=”retreat_anterior”>
<label for=”retreat_anterior”>Retreat-uri pentru cupluri</label>
</div>
<div class=”checkbox-item”>
<input type=”checkbox” id=”conferinte_familia” name=”participari_anterioare” value=”conferinte_familia”>
<label for=”conferinte_familia”>Conferințe despre familie</label>
</div>
<div class=”checkbox-item”>
<input type=”checkbox” id=”seminarii_casatorie” name=”participari_anterioare” value=”seminarii_casatorie”>
<label for=”seminarii_casatorie”>Seminarii despre căsătorie</label>
</div>
<div class=”checkbox-item”>
<input type=”checkbox” id=”prima_participare” name=”participari_anterioare” value=”prima_participare”>
<label for=”prima_participare”>Prima participare</label>
</div>
</div>
</div>

<div class=”section-title”>Așteptări și Nevoi</div>

<div class=”form-group”>
<label for=”asteptari”>Ce așteptări aveți de la acest retreat?</label>
<textarea id=”asteptari” name=”asteptari” placeholder=”Descrieți ce sperați să obțineți din această experiență…”></textarea>
</div>

<div class=”form-group”>
<label for=”nevoi_speciale”>Aveți nevoi speciale sau restricții de care organizatorii ar trebui să știe?</label>
<textarea id=”nevoi_speciale” name=”nevoi_speciale” placeholder=”Ex: restricții alimentare, nevoi medicale, etc.”></textarea>
</div>

<div class=”form-group”>
<label for=”cum_aflat”>Cum ați aflat despre acest retreat?</label>
<select id=”cum_aflat” name=”cum_aflat”>
<option value=””>Selectați o opțiune</option>
<option value=”biserica”>Prin biserica noastră</option>
<option value=”prieteni”>Prin prieteni</option>
<option value=”social_media”>Social media</option>
<option value=”website”>Website-ul bisericii</option>
<option value=”flyer”>Flyer/Poster</option>
<option value=”altele”>Altele</option>
</select>
</div>

<button type=”submit” class=”submit-btn”>
<span class=”heart-icon”>♥</span> Trimite înscrierea <span class=”heart-icon”>♥</span>
</button>
</form>
</div>
</div>

<script>
document.getElementById(‘coupleForm’).addEventListener(‘submit’, function(e) {
e.preventDefault();

// Collect form data
const formData = new FormData(this);
const data = {};

// Handle regular inputs
for (let [key, value] of formData.entries()) {
if (key === ‘participari_anterioare’) {
if (!data[key]) data[key] = [];
data[key].push(value);
} else {
data[key] = value;
}
}

// Handle contribution options
const contributionRadios = document.querySelectorAll(‘input[name=”contributie”]’);
const customAmountField = document.getElementById(‘custom_amount_field’);

contributionRadios.forEach(radio => {
radio.addEventListener(‘change’, function() {
// Remove selected class from all radio items
document.querySelectorAll(‘.radio-item’).forEach(item => {
item.classList.remove(‘selected’);
});

// Add selected class to current item
this.closest(‘.radio-item’).classList.add(‘selected’);

// Show/hide custom amount field
if (this.value === ‘alta’) {
customAmountField.classList.add(‘show’);
document.getElementById(‘suma_personalizata’).required = true;
} else {
customAmountField.classList.remove(‘show’);
document.getElementById(‘suma_personalizata’).required = false;
}
});
});

// Show success message
alert(‘Mulțumim pentru înscrierea dumneavoastră! Veți fi contactați în curând cu mai multe detalii despre retreat.’);

// Log the data (in a real application, this would be sent to a server)
console.log(‘Form submitted with data:’, data);
});

// Add some interactive feedback
const inputs = document.querySelectorAll(‘input, textarea, select’);
inputs.forEach(input => {
input.addEventListener(‘focus’, function() {
this.parentElement.style.transform = ‘scale(1.02)’;
});

input.addEventListener(‘blur’, function() {
this.parentElement.style.transform = ‘scale(1)’;
});
});
</script>
</body>
</html>