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index.html
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<!DOCTYPE html>
<html lang="en">
<head>
<!-- Basic Page Needs
–––––––––––––––––––––––––––––––––––––––––––––––––– -->
<meta charset="utf-8">
<title>Your page title here :)</title>
<meta name="description" content="">
<meta name="author" content="">
<!-- Mobile Specific Metas
–––––––––––––––––––––––––––––––––––––––––––––––––– -->
<meta name="viewport" content="width=device-width, initial-scale=1, maximum-scale=1">
<!-- FONT
–––––––––––––––––––––––––––––––––––––––––––––––––– -->
<link href='http://fonts.googleapis.com/css?family=Raleway:400,300,600' rel='stylesheet' type='text/css'>
<!-- CSS
–––––––––––––––––––––––––––––––––––––––––––––––––– -->
<link rel="stylesheet" href="css/normalize.css">
<link rel="stylesheet" href="css/skeleton.css">
<link rel="stylesheet" href="css/styles.css">
<link rel="stylesheet" href="css/sweet-alert.css">
<!-- Favicon
–––––––––––––––––––––––––––––––––––––––––––––––––– -->
<link rel="icon" type="image/png" href="images/favicon.png" />
</head>
<body>
<!-- Primary Page Layout
–––––––––––––––––––––––––––––––––––––––––––––––––– -->
<div class="container">
<form class="form" accept-charset="UTF-8" action="https://formkeep.com/f/d6aa95483742" method="POST">
<input type="hidden" name="utf8" value="✓">
<!-- Progress Bar -->
<div class="row">
<ul class="progress-bar">
<li class="active">Personal Information</li>
<li>Emergency Contact</li>
<li>Employer Information</li>
</ul>
</div><!-- .row -->
<!-- Step one -->
<fieldset>
<div class="step-one row">
<div class="twelve columns">
<h1>ICSM Medical Center Application</h1>
<h4>Tell us about yourself</h4>
<div class="form1">
<div class="row">
<div class="four columns">
<label for="fname">Your first name:</label>
<input type="text" name="name" id="fname" placeholder="John" />
</div>
<div class="four columns">
<label for="mname">Your middle name:</label>
<input type="text" name="mname" id="mname" placeholder="Quincy" />
</div>
<div class="four columns">
<label for="lname">Your last name:</label>
<input type="text" name="lname" id="lname" placeholder="Doe" />
</div>
</div><!-- .row -->
<div class="row">
<div class="four columns">
<label for="gender">Your gender</label>
<select id="gender">
<option placeholder="Option 1" selected>Select your gender</option>
<option placeholder="Option 2">Male</option>
<option placeholder="Option 3">Female</option>
</select>
</div><!-- .four -->
<div class="four columns">
<label for="lang">Your language:</label>
<select id="lang">
<option placeholder="Option 1" selected>Select your language</option>
<option placeholder="Option 2">English</option>
<option placeholder="Option 3">Spanish</option>
<option placeholder="Option 4">Other</option>
</select>
</div><!-- .four -->
<div class="four columns">
<label for="race">Your Ethnicity:</label>
<select id="race">
<option placeholder="Option 1" selected>Select your Ethnicity</option>
<option placeholder="Option 2">Alaskan Native</option>
<option placeholder="Option 2">American Indian</option>
<option placeholder="Option 3">Asian/Asian American</option>
<option placeholder="Option 4">Black/African American</option>
<option placeholder="Option 5">Hispanic/Latino</option>
<option placeholder="Option 6">Native Hawaiian</option>
<option placeholder="Option 6">Other Pacfic Island</option>
<option placeholder="Option 7">White/Euro American</option>
</select>
</div><!-- .four -->
</div><!-- .row -->
<div class="row">
<div class="four columns">
<label for="dob">Your birthdate:</label>
<input type="date" name="dob" id="dob" placeholder="Date of Birth" />
</div><!-- .one-half -->
</div><!-- .row -->
<div class="row">
<div class="twelve columns">
<input class="button-primary four columns offset-by-eight column next action-button" type="button" name="next" value="Next Step" />
</div><!-- .twelve -->
</div><!-- .row -->
</div><!-- .form -->
</div><!-- .twelve -->
</div><!-- .step-one -->
</fieldset>
<!-- Step two -->
<fieldset>
<div class="step-two">
<div class="twelve columns">
<h1>ICSM Medical Center Application</h1>
<h4>Just a few more questions about yourself...</h4>
<div class="form1">
<div class="row">
<div class="four columns">
<label for="street">Your mailing address:</label>
<input type="text" name="street" id="street" placeholder="123 N. Main St."/>
</div><!-- .four -->
<div class="four columns">
<label for="city">Your City, & State:</label>
<input type="text" name="city" id="city" placeholder="Martinsville, Va." />
</div><!-- .four -->
<div class="four columns">
<label for="zip">Your Zipcode:</label>
<input type="text" name="zip" id="zip" placeholder="24523" />
</div><!-- .four -->
</div><!-- .row -->
<div class="row">
<div class="four columns">
<label for="phone">Your Primary Phone:</label>
<input type="tel" name="phone" id="phone" placeholder="123-555-1234" />
</div><!-- .six -->
<div class="four columns">
<label for="phone2">Additional Phone:</label>
<input type="tel" name="phone2" id="phone2" placeholder="123-555-1234" />
</div><!-- .six -->
<div class="four columns">
<label for="email">Your eMail:</label>
<input type="email" name="email" id="email" placeholder="[email protected]" />
</div><!-- .four -->
</div><!-- .row -->
<div class="row">
<div class="four columns">
<label for="econtact">Emergency Contact </br>Full Name:</label>
<input type="text" name="econtact" id="econtact" placeholder="Jane Doe" />
</div><!-- .four -->
<div class="four columns">
<label for="econtactrelationship">Emergency Contact </br>Relationship to You:</label>
<input type="text" name="econtactrelationship" id="econtactrelationship" placeholder="Mother" />
</div><!-- .four -->
<div class="four columns">
<label for="econtactphone">Emergency Contact </br> Phone Number:</label>
<input type="text" name="econtactphone" id="econtactphone" placeholder="911-123-4321" />
</div><!-- .four -->
</div><!-- .row -->
<div class="row">
<div class="twelve columns">
<input class="button-primary four columns previous action-button" type="button" name="previous" value="Previous Step" />
<input class="button-primary four columns offset-by-four column next action-button" type="button" name="next" value="Next Step" />
</div><!-- .twelve -->
</div><!-- .row -->
</div><!-- .form -->
</div><!-- .twelve -->
</div><!-- .step-two -->
</fieldset>
<!-- Step three -->
<fieldset>
<div class="step-three">
<div class="twelve columns">
<h1>ICSM Medical Center Application</h1>
<h4>Last Step! Tell us about your Employer</h4>
<div class="row">
<div class="four columns">
<label for="ename">Employer/Company Name:</label>
<input type="text" name="ename" id="ename" placeholder="Acme Painting Inc." />
</div><!-- .four -->
<div class="four columns">
<label for="ephone">Employer Phone Number:</label>
<input type="text" name="ephone" id="ephone" placeholder="1-800-123-4567" />
</div><!-- .four -->
<div class="four columns">
<label for="eemail">Employer eMail:</label>
<input type="text" name="work-email" id="email" placeholder="[email protected]" />
</div><!-- .four -->
</div><!-- .row -->
<div class="row">
<div class="four columns">
<label for="eaddress">Employer Address:</label>
<input type="text" name="eaddress" id="eaddress" placeholder="PO Box 4321" />
</div><!-- .four -->
<div class="four columns">
<label for="ecity">Employer City/State:</label>
<input type="text" name="ecity" id="ecity" placeholder="Lynchburg, Va." />
</div><!-- .four -->
<div class="four columns">
<label for="ezip">Employer Zipcode:</label>
<input type="text" name="ezip" id="ezip" placeholder="24523" />
</div><!-- .four -->
</div><!-- .row -->
<div class="row">
<div class="four columns">
<label for="discover">How did you discover ICSM Medical Center Application</label>
<select id="discover">
<option placeholder="Option 1" selected>Select a choice below</option>
<option placeholder="Option 2">Website</option>
<option placeholder="Option 3">Brochure</option>
<option placeholder="Option 3">Newspaper</option>
<option placeholder="Option 4">Other</option>
</select>
</div><!-- .four -->
</div><!-- .row -->
<div class="row">
<div class="twelve columns">
<input class="button-primary four columns previous action-button" type="button" name="previous" value="Previous Step" />
<input class="button-primary four columns offset-by-four column next action-button" type="submit" name="next" value="Submit Application" />
</div><!-- .twelve -->
</div><!-- .row -->
</div><!-- .twelve -->
</div><!-- .step-three -->
</fieldset>
<fieldset>
<div class="step-three">
<div class="twelve columns">
<h1>ICSM Medical Center Application</h1>
<h4>Your application has been successfully submitted!</h4>
</div><!-- .twelve -->
</div><!-- .step-three -->
</fieldset>
</form>
<!-- End Document
–––––––––––––––––––––––––––––––––––––––––––––––––– -->
<!-- jQuery -->
<script type="text/javascript" src="http://cdnjs.cloudflare.com/ajax/libs/jquery/2.1.1/jquery.min.js"></script>
<script type="text/javascript" src="js/jquery.easing.1.3.js"></script>
<script type="text/javascript" src="js/sweet-alert.min.js"></script>
<script type="text/javascript" src="js/theMagic.js"></script>
</body>
</html>