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EmpowerHER Coastal Friendsgiving Escape

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  <body>
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    <field type="header" subtype="h2" label="Contact Information"/>
    <field type="text" subtype="text" required="true" label="First name" name="first-name" className="form-control"/>
    <field type="text" subtype="text" label="Middle name" name="middle-name" className="form-control"/>
    <field type="text" subtype="text" required="true" label="Last name" name="last-name" className="form-control"/>
    <field type="text" subtype="text" label="Preferred name (nickname)" name="preferred-name" className="form-control"/>
    <field type="text" subtype="text" required="true" label="Primary email address" name="email" className="form-control"/>
    <field type="text" subtype="text" label="Primary phone number" name="phone-number" className="form-control"/>
    <field type="header" subtype="h2" label="Passport Information"/>
    <field type="text" subtype="text" label="Full name as it appears on passport" name="passport-name" className="form-control"/>
    <field type="text" subtype="text" label="Passport number" name="passport-number" className="form-control"/>
    <field type="text" subtype="text" label="Country of issue" name="passport-country-of-issue" className="form-control"/>
    <field type="date" label="Date of birth" name="birthday" className="form-control"/>
    <field type="date" label="Date of issue" name="passport-date-of-issue" className="form-control"/>
    <field type="date" label="Date of expiration" name="passport-date-of-expiration" className="form-control"/>
    <field type="radio-group" label="Gender" name="gender">
      <option value="female" label="F">F</option>
      <option value="male" label="M">M</option>
      <option value="other" label="X">X</option>
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    <field type="header" subtype="h2" label="Emergency Contact Information"/>
    <field type="text" subtype="text" label="Full name" name="emergency-contact-full-name" className="form-control"/>
    <field type="text" subtype="text" label="Phone number" name="emergency-contact-phone-number" className="form-control"/>
    <field type="text" subtype="text" label="Relationship to you" name="emergency-contact-relationship" className="form-control"/>
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</body>
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<html>
  <body>
<form-template>
  <fields>
    <field type="header" subtype="h2" label="Contact Information"/>
    <field type="text" subtype="text" required="true" label="First name" name="first-name" className="form-control"/>
    <field type="text" subtype="text" label="Middle name" name="middle-name" className="form-control"/>
    <field type="text" subtype="text" required="true" label="Last name" name="last-name" className="form-control"/>
    <field type="text" subtype="text" label="Preferred name (nickname)" name="preferred-name" className="form-control"/>
    <field type="text" subtype="text" required="true" label="Primary email address" name="email" className="form-control"/>
    <field type="text" subtype="text" label="Primary phone number" name="phone-number" className="form-control"/>
    <field type="header" subtype="h2" label="Passport Information"/>
    <field type="text" subtype="text" label="Full name as it appears on passport" name="passport-name" className="form-control"/>
    <field type="text" subtype="text" label="Passport number" name="passport-number" className="form-control"/>
    <field type="text" subtype="text" label="Country of issue" name="passport-country-of-issue" className="form-control"/>
    <field type="date" label="Date of birth" name="birthday" className="form-control"/>
    <field type="date" label="Date of issue" name="passport-date-of-issue" className="form-control"/>
    <field type="date" label="Date of expiration" name="passport-date-of-expiration" className="form-control"/>
    <field type="radio-group" label="Gender" name="gender">
      <option value="female" label="F">F</option>
      <option value="male" label="M">M</option>
      <option value="other" label="X">X</option>
    </field>
    <field type="header" subtype="h2" label="Emergency Contact Information"/>
    <field type="text" subtype="text" label="Full name" name="emergency-contact-full-name" className="form-control"/>
    <field type="text" subtype="text" label="Phone number" name="emergency-contact-phone-number" className="form-control"/>
    <field type="text" subtype="text" label="Relationship to you" name="emergency-contact-relationship" className="form-control"/>
  </fields>
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</body>
</html>

<html>
  <body>
<form-template>
  <fields>
    <field type="header" subtype="h2" label="Contact Information"/>
    <field type="text" subtype="text" required="true" label="First name" name="first-name" className="form-control"/>
    <field type="text" subtype="text" label="Middle name" name="middle-name" className="form-control"/>
    <field type="text" subtype="text" required="true" label="Last name" name="last-name" className="form-control"/>
    <field type="text" subtype="text" label="Preferred name (nickname)" name="preferred-name" className="form-control"/>
    <field type="text" subtype="text" label="Primary email address" name="email" className="form-control"/>
    <field type="text" subtype="text" label="Primary phone number" name="phone-number" className="form-control"/>
    <field type="header" subtype="h2" label="Passport Information"/>
    <field type="text" subtype="text" label="Full name as it appears on passport" name="passport-name" className="form-control"/>
    <field type="text" subtype="text" label="Passport number" name="passport-number" className="form-control"/>
    <field type="text" subtype="text" label="Country of issue" name="passport-country-of-issue" className="form-control"/>
    <field type="date" label="Date of birth" name="birthday" className="form-control"/>
    <field type="date" label="Date of issue" name="passport-date-of-issue" className="form-control"/>
    <field type="date" label="Date of expiration" name="passport-date-of-expiration" className="form-control"/>
    <field type="radio-group" label="Gender" name="gender">
      <option value="female" label="F">F</option>
      <option value="male" label="M">M</option>
      <option value="other" label="X">X</option>
    </field>
    <field type="header" subtype="h2" label="Emergency Contact Information"/>
    <field type="text" subtype="text" label="Full name" name="emergency-contact-full-name" className="form-control"/>
    <field type="text" subtype="text" label="Phone number" name="emergency-contact-phone-number" className="form-control"/>
    <field type="text" subtype="text" label="Relationship to you" name="emergency-contact-relationship" className="form-control"/>
  </fields>
</form-template>
</body>
</html>

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EmpowerHER Coastal Friendsgiving Escape

EmpowerHER Coastal Friendsgiving Escape

Hosted Experience RSVP Fee —

—

Convenience fee —

Total —

Due now —

Continue to traveler info

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Payment schedule

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Final payment of $21.04 is due on October 1, 2026

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$21.04

Note: By paying, you agree to the following Terms & Conditions

Terms & Conditions

I authorize EmpowerHer Escapes to charge the credit card or bank account indicated on this invoice for the noted amount on today's date. This payment is for the Trip Deposit described on the invoice. I understand that all Deposit payments made to EmpowerHer Escapes are non-refundable. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company, so long as the transaction corresponds to the terms indicated on this invoice.

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EmpowerHER Coastal Friendsgiving Escape

Hosted Experience RSVP Fee —

—

Convenience fee —

Total —

Due now —

Continue to traveler info