<link href="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/js/bootstrap.min.js"></script> <script src="//code.jquery.com/jquery-1.11.1.min.js"></script> <!------ Include the above in your HEAD tag ----------> <form class="form-horizontal"> <fieldset> <!-- Form Name --> <legend>Registro Accidentes</legend> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="Colegio">Colegio</label> <div class="col-md-4"> <select id="Colegio" name="Colegio" class="form-control"> <option value="1">DG La Granja</option> <option value="2">DG El Bosque</option> <option value="3">DG Lo Prado</option> <option value="4">Stgo La Florida</option> <option value="5">Stgo Pudahuel</option> <option value="6">Stgo Quilicura</option> <option value="7">Stgo Emprendedores</option> </select> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="Dia">Día del accidente</label> <div class="col-md-4"> <select id="Dia" name="Dia" class="form-control"> <option value="1">1</option> <option value="2">2</option> <option value="3">3</option> <option value="4">4</option> <option value="5">5</option> <option value="6">6</option> <option value="7">7</option> <option value="8">8</option> <option value="9">9</option> <option value="10">10</option> <option value="11">11</option> <option value="12">12</option> <option value="13">13</option> <option value="14">14</option> <option value="15">15</option> <option value="16">16</option> <option value="17">17</option> <option value="18">18</option> <option value="19">19</option> <option value="20">20</option> <option value="21">21</option> <option value="22">22</option> <option value="23">23</option> <option value="24">24</option> <option value="25">25</option> <option value="26">26</option> <option value="27">27</option> <option value="28">28</option> <option value="29">29</option> <option value="30">30</option> <option value="31">31</option> </select> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="Hora">Hora</label> <div class="col-md-4"> <input id="Hora" name="Hora" type="text" placeholder="hh:mm" class="form-control input-md" required=""> <span class="help-block">Formato (hora:minutos)</span> </div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="Sexo">Sexo</label> <div class="col-md-4"> <label class="radio-inline" for="Sexo-0"> <input type="radio" name="Sexo" id="Sexo-0" value="1" checked="checked"> Hombre </label> <label class="radio-inline" for="Sexo-1"> <input type="radio" name="Sexo" id="Sexo-1" value="2"> Mujer </label> </div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="Seguro">Seguro</label> <div class="col-md-4"> <label class="radio-inline" for="Seguro-0"> <input type="radio" name="Seguro" id="Seguro-0" value="1" checked="checked"> Sí </label> <label class="radio-inline" for="Seguro-1"> <input type="radio" name="Seguro" id="Seguro-1" value="0"> No </label> </div> </div> <!-- Multiple Radios --> <div class="form-group"> <label class="col-md-4 control-label" for="Tipo">Tipo</label> <div class="col-md-4"> <div class="radio"> <label for="Tipo-0"> <input type="radio" name="Tipo" id="Tipo-0" value="1" checked="checked"> Accidente </label> </div> <div class="radio"> <label for="Tipo-1"> <input type="radio" name="Tipo" id="Tipo-1" value="2"> Enfermedad </label> </div> </div> </div> <!-- Multiple Radios --> <div class="form-group"> <label class="col-md-4 control-label" for="Intensidad">Intensidad</label> <div class="col-md-4"> <div class="radio"> <label for="Intensidad-0"> <input type="radio" name="Intensidad" id="Intensidad-0" value="1" checked="checked"> Leve </label> </div> <div class="radio"> <label for="Intensidad-1"> <input type="radio" name="Intensidad" id="Intensidad-1" value="2"> Media </label> </div> <div class="radio"> <label for="Intensidad-2"> <input type="radio" name="Intensidad" id="Intensidad-2" value="3"> Grave </label> </div> </div> </div> <!-- Select Multiple --> <div class="form-group"> <label class="col-md-4 control-label" for="Lugar">Lugar</label> <div class="col-md-5"> <select id="Lugar" name="Lugar" class="form-control" multiple="multiple"> <option value="1">Trayecto</option> <option value="2">Sala</option> <option value="3">Escala</option> <option value="4">Patio/Recreo</option> <option value="5">Gimnasio</option> <option value="6">Taller (Clase)</option> <option value="7">Casino</option> <option value="8">Otro</option> </select> </div> </div> <!-- Textarea --> <div class="form-group"> <label class="col-md-4 control-label" for="Descripcion">Descripcion</label> <div class="col-md-4"> <textarea class="form-control" id="Descripcion" name="Descripcion">Objeto, circunstancia, referencia</textarea> </div> </div> <!-- Button (Double) --> <div class="form-group"> <label class="col-md-4 control-label" for="Controles">Agregar Caso</label> <div class="col-md-8"> <button id="Controles" name="Controles" class="btn btn-success">Agregar Caso</button> <button id="button2id" name="button2id" class="btn btn-danger">Borrar Datos</button> </div> </div> </fieldset> </form>