Clara Rosa Hospital Utawala

Compassion | Competence

{{ $scheme->name }} — Member Enrolment
Fill in your details below to register for cover under your SACCO. Your SACCO will confirm your enrolment and activate your cover once your first premium is paid. All fields marked * are required.

@if($errors->any())

Please fix the following before submitting:

{{ $err }}

@endif

@csrf {{-- Honeypot — hidden from humans, bots will fill it --}} {{-- ═══════════ Membership Number ═══════════ --}}

SACCO Membership

{{ strtoupper($scheme->code) }} Membership Number * @php // Strip prefix from old() so the input shows only digits if the // form bounces back with errors. $oldNumber = old('member_number', ''); $prefix = strtoupper($scheme->code) . '-'; if (str_starts_with(strtoupper($oldNumber), $prefix)) { $oldNumber = substr($oldNumber, strlen($prefix)); } @endphp

Type just your number (e.g. 001). The {{ $prefix }} prefix is added automatically.

@error('member_number')

@enderror

Your Details

First Name * @error('first_name')

@enderror

Middle Name

Last Name * @error('last_name')

@enderror

Sex *

M F

@error('gender')

@enderror

Date of Birth * @error('date_of_birth')

@enderror

National ID Number * @error('id_number')

@enderror

Phone *

Starts with 07 or 01, 10 digits.

@error('phone')

@enderror

Address — Estate / Village

Sub-County

Default Embakasi East — change if different.

County

Next of Kin (Wife)

Optional — only fill if you have a wife.

{{-- Template for the wife card — cloned by JS when "Add wife" is tapped. Only one wife card is allowed at a time. NOK fields use the same patient columns the controller already writes to (nok_name, nok_phone, nok_id_number), so storage logic is unchanged — the form just reveals/hides the inputs. --}} {{-- ═══════════ Children ═══════════ --}}

Children (Under 18 Years)

Optional — only fill if you have children. You can add up to 5.

{{-- Template for a single child card — cloned by JS when "Add a child" is tapped. Field names use a placeholder `__I__` that JS replaces with the row index. --}} {{-- ═══════════ Consent ═══════════ --}}