<div class="span12 row"> <?php if(isset($data->error)): ?> <?php foreach($data->error as $error): ?> <p class="error-form"><?php echo $error; ?></p> <?php endforeach; ?> <?php endif; ?> <form method="post" action="<?php echo \Request::url(); ?>/bedankt" class="default subscribe" autocomplete="off"> <label class="first_name"><span>Voornaam<em>*</em></span><input name="first_name" type="text" placeholder="Voornaam" required></label> <label class="sur_name"><span>Achternaam<em>*</em></span><input name="sur_name" type="text" placeholder="Achternaam" required></label> <div><span>Geslacht<em>*</em></span> <div class="value-row"> <label class="radiobox"><input type="radio" class="not-full-size" name="sex" value="Man" required><span>Man</span></label> <label class="radiobox"><input type="radio" class="not-full-size" name="sex" value="Vrouw"><span>Vrouw</span></label> </div> </div> <label class="birthdate"><span>Geboortedatum<em>*</em></span><input name="birthdate" type="text" placeholder="dd/mm/yyyy" required></label> <label class="adres"><span>Straatnaam + Huisnummer<em>*</em></span><input name="adres" type="text" placeholder="Staatnaam" required><input name="streetnumber" type="text" placeholder="Nr" required></label> <label class="postal"><span>Postcode<em>*</em></span><input name="zip" type="text" placeholder="Postcode" required></label> <label class="city"><span>Woonplaats<em>*</em></span><input name="city" type="text" placeholder="Woonplaats" required></label> <label class="country"><span>Land</span><input name="country" type="text" placeholder="Land"></label> <label class="phone"><span>Telefoon</span><input name="phone" type="tel" placeholder="Telefoon"></label> <label class="email"><span>Email<em>*</em></span><input name="email" type="email" placeholder="Email" required></label> <div> <span>Korting</span> <div class="value-row"> <label class="radiobox"><input type="radio" class="not-full-size" name="age" value="Geen"><span>Geen</span></label> <label class="radiobox"><input type="radio" class="not-full-size" name="age" value="Student"><span>Student</span></label> <label class="radiobox"><input type="radio" class="not-full-size" name="age" value="Plus 55"><span>55+</span></label> </div> </div> <div> <div class="value-row extraInfo"> <label class="checkboxer"><input name="fitness[]" class="not-full-size" type="checkbox" value="Start to be Fit"><span>Ja, ik wil gebruik maken voor het Start to be Fit proefabonnement van 4 weken onbeperkt sporten voor € 19,50.</span></label> </div> </div> <div> <span>Lidmaatschap<em>*</em></span> <div class="value-row"> <label class="radiobox"><input type="radio" class="not-full-size" name="amount" value="52 beurten" required><span>52 beurten</span></label> <label class="radiobox"><input type="radio" class="not-full-size" name="amount" value="1x per week"><span>1x per week</span></label> <label class="radiobox"><input type="radio" class="not-full-size" name="amount" value="Onbeperkt"><span>Onbeperkt</span></label> </div> </div> <div class="value-row extraInfo"> <label class="checkboxer"><input name="newsletter" class="not-full-size" type="checkbox" value="ja"><span>Ja, ik wil de maandelijkse Sportivo nieuwsbrief ontvangen.</span></label> <label class="checkboxer"><input name="alreadySportivo" class="not-full-size" type="checkbox" value="ja"><span>Ja, ik ben eerder lid geweest van Sportivo.</span></label> </div> <div class="value-row submit-container"> <p><em>*</em> velden zijn verplicht</p> <input type="submit" name="submit" class="submit" value="Verzenden"> </div> </form> </div>