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form.html
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<div class="container">
<header class="text-center"></header>
<h1>Create your profile</h1>
<div class="content-block">
<form>
<input name="_token" type="hidden" value="AfeV5yld2vy6R1AbJ1HaOF7QqwQx4aZSThmEHsCt">
<h2>Name</h2>
<div class="well">
<div class="row">
<div class="col-sm-4">
<div class="form-group ">
<label for="firstName" class="control-label">First name</label>
<input class="form-control" id="firstName" maxlength="100" placeholder="required"
name="firstName" type="text">
</div>
</div>
<div class="col-sm-4">
<div class="form-group ">
<label for="lastName" class="control-label">Last name</label>
<input class="form-control" id="lastName" maxlength="100" placeholder="required"
name="lastName" type="text">
</div>
</div>
</div>
</div>
<h2>Contact info</h2>
<div class="well">
<div class="row">
<div class="col-md-6">
<div class="form-group ">
<label for="email" class="control-label">Email address</label>
<input class="form-control" id="email" maxlength="255" placeholder="required" name="email"
type="text">
</div>
</div>
<div class="col-md-6">
<div class="form-group ">
<label for="email_confirmation" class="control-label">Re-enter email</label>
<input class="form-control" id="email_confirmation" maxlength="255" placeholder="required"
name="email_confirmation" type="email">
</div>
</div>
</div>
<div class="row">
<div class="col-md-6">
<div class="form-group ">
<label for="phone" class="control-label">Phone number</label>
<input class="form-control" id="phone" maxlength="20" name="phone" type="text">
</div>
</div>
<div class="col-md-6">
<div class="form-group ">
<label for="state" class="control-label">State</label>
<select class="form-control" id="state" name="state">
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
</div>
</div>
</div>
</div>
<h2>Login credentials</h2>
<div class="well">
<div class="row">
<div class="col-md-4">
<div class="form-group ">
<label for="username" class="control-label">Username</label>
<input class="form-control" id="username" maxlength="100" placeholder="required"
name="username" type="text">
</div>
</div>
<div class="col-md-4">
<div class="form-group ">
<label for="password" class="control-label">Password</label>
<input class="form-control" id="password" maxlength="255" placeholder="required"
name="password" type="password" value="">
</div>
</div>
<div class="col-md-4">
<div class="form-group ">
<label for="password_confirmation" class="control-label">Re-enter password</label>
<input class="form-control" id="password_confirmation" maxlength="255"
placeholder="required" name="password_confirmation" type="password" value="">
</div>
</div>
</div>
</div>
</form>
</div>
<div class="row roomy">
<div class="col-sm-offset-4 col-sm-4">
<input class="btn btn-lg btn-primary btn-block" type="submit" value="Register">
</div>
</div>
<footer class="row roomy">
<div class="col-xs-12 text-center">
Copyright © 2016 Psych Origins
</div>
</footer>
</div>