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<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="radio-group" required="true" label="Gender" name="sex">&#13;
			<option label="M" value="m">M</option>&#13;
			<option label="F" value="f">F</option>&#13;
			<option label="X" value="x">X</option>&#13;
		</field>&#13;
		<field type="text" required="true" label="First name" name="first-name" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Last name" name="last-name" subtype="text" className="form-control"/>&#13;
		<field type="date" required="true" label="Birthday" name="birthday" className="form-control"/>&#13;
		<field type="clientLoyaltyPrograms" label="VIFP Number (For Carnival Past Guest)" description="VIFP Number (For Carnival Past Guest)" name="loyalty-program" loyalty-program-note="*** This field allows your client to enter multiple loyalty program numbers (you only need one of these per form template) ***" className="form-control"/>&#13;
		<field type="header" subtype="h2" label="Address"/>&#13;
		<field type="text" label="Line 1" name="address-line-1" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Line 2" name="address-line-2" subtype="text" className="form-control"/>&#13;
		<field type="text" label="City" name="address-city" subtype="text" className="form-control"/>&#13;
		<field type="text" label="State" name="address-state" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Zip" name="address-zip" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Country" name="address-country" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Email" name="email" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="checkbox-group" label="Medical" description="Wheelchair Assistance Is Only Available For Embarkation and Debarkation when Guest Isn&#39;t Bring Their Own Wheelchair" name="medical">&#13;
			<option label="WHEELCHAIR ASSISTANCE" value="wheelchair-assistance">WHEELCHAIR ASSISTANCE</option>&#13;
			<option label="COGNITIVE DISABILITIES" value="cognitive-disabilities">COGNITIVE DISABILITIES</option>&#13;
			<option label="CONCENTRATOR" value="concentrator">CONCENTRATOR</option>&#13;
			<option label="DIABETIC  " value="diabetic-">DIABETIC  </option>&#13;
			<option label="AUTISM  " value="autism-">AUTISM  </option>&#13;
			<option label="BLIND OR LOW VISION" value="blind-or-low-vision">BLIND OR LOW VISION</option>&#13;
			<option label="DEAF" value="deaf">DEAF</option>&#13;
			<option label="ALLERGIES" value="allergies">ALLERGIES</option>&#13;
			<option label="PREGNANT LESS 24 FULL WKS " value="pregnant-less-24-full-wks-">PREGNANT LESS 24 FULL WKS </option>&#13;
			<option label="SHARPS CONTAINER" value="sharps-container">SHARPS CONTAINER</option>&#13;
			<option label="DIALYSIS" value="dialysis">DIALYSIS</option>&#13;
			<option label="WHEELCHAIR" value="wheelchair">WHEELCHAIR</option>&#13;
			<option label="PREG MORE THAN 24 FULL WKS" value="preg-more-than-24-full-wks">PREG MORE THAN 24 FULL WKS</option>&#13;
			<option label="OXYGEN " value="oxygen-">OXYGEN </option>&#13;
		</field>&#13;
		<field type="textarea" label="Message" name="message" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="TRAVEL INSURANCE"/>&#13;
		<field type="paragraph" subtype="p" label="By signing below, I understand that declining travel insurance could result in the loss of my travel cost and/or require more money to correct the situation. I also acknowledge that without insurance, there may be no way to recoup any losses, costs or expenses incurred."/>&#13;
		<field type="radio-group" required="true" label="Please choose:" name="please-choose">&#13;
			<option label="I ACCEPT Travel Insurance." value="i-accept-travel-insurance">I ACCEPT Travel Insurance.</option>&#13;
			<option label="I DECLINE Travel Insurance. I understand that this could result in the loss of ALL of my travel costs." value="i-decline-travel-insurance-i-understand-that-this-could-result-in-the-loss-of-all-of-my-travel-costs">I DECLINE Travel Insurance. I understand that this could result in the loss of ALL of my travel costs.</option>&#13;
		</field>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="radio-group" required="true" label="Gender" name="sex">&#13;
			<option label="M" value="m">M</option>&#13;
			<option label="F" value="f">F</option>&#13;
			<option label="X" value="x">X</option>&#13;
		</field>&#13;
		<field type="text" required="true" label="First name" name="first-name" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Last name" name="last-name" subtype="text" className="form-control"/>&#13;
		<field type="date" required="true" label="Birthday" name="birthday" className="form-control"/>&#13;
		<field type="clientLoyaltyPrograms" label="VIFP Number (For Carnival Past Guest)" description="VIFP Number (For Carnival Past Guest)" name="loyalty-program" loyalty-program-note="*** This field allows your client to enter multiple loyalty program numbers (you only need one of these per form template) ***" className="form-control"/>&#13;
		<field type="header" subtype="h2" label="Address"/>&#13;
		<field type="text" label="Line 1" name="address-line-1" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Line 2" name="address-line-2" subtype="text" className="form-control"/>&#13;
		<field type="text" label="City" name="address-city" subtype="text" className="form-control"/>&#13;
		<field type="text" label="State" name="address-state" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Zip" name="address-zip" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Country" name="address-country" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Email" name="email" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="checkbox-group" label="Medical" description="Wheelchair Assistance Is Only Available For Embarkation and Debarkation when Guest Isn&#39;t Bring Their Own Wheelchair" name="medical">&#13;
			<option label="WHEELCHAIR ASSISTANCE" value="wheelchair-assistance">WHEELCHAIR ASSISTANCE</option>&#13;
			<option label="COGNITIVE DISABILITIES" value="cognitive-disabilities">COGNITIVE DISABILITIES</option>&#13;
			<option label="CONCENTRATOR" value="concentrator">CONCENTRATOR</option>&#13;
			<option label="DIABETIC  " value="diabetic-">DIABETIC  </option>&#13;
			<option label="AUTISM  " value="autism-">AUTISM  </option>&#13;
			<option label="BLIND OR LOW VISION" value="blind-or-low-vision">BLIND OR LOW VISION</option>&#13;
			<option label="DEAF" value="deaf">DEAF</option>&#13;
			<option label="ALLERGIES" value="allergies">ALLERGIES</option>&#13;
			<option label="PREGNANT LESS 24 FULL WKS " value="pregnant-less-24-full-wks-">PREGNANT LESS 24 FULL WKS </option>&#13;
			<option label="SHARPS CONTAINER" value="sharps-container">SHARPS CONTAINER</option>&#13;
			<option label="DIALYSIS" value="dialysis">DIALYSIS</option>&#13;
			<option label="WHEELCHAIR" value="wheelchair">WHEELCHAIR</option>&#13;
			<option label="PREG MORE THAN 24 FULL WKS" value="preg-more-than-24-full-wks">PREG MORE THAN 24 FULL WKS</option>&#13;
			<option label="OXYGEN " value="oxygen-">OXYGEN </option>&#13;
		</field>&#13;
		<field type="textarea" label="Message" name="message" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="TRAVEL INSURANCE"/>&#13;
		<field type="paragraph" subtype="p" label="By signing below, I understand that declining travel insurance could result in the loss of my travel cost and/or require more money to correct the situation. I also acknowledge that without insurance, there may be no way to recoup any losses, costs or expenses incurred."/>&#13;
		<field type="radio-group" required="true" label="Please choose:" name="please-choose">&#13;
			<option label="I ACCEPT Travel Insurance." value="i-accept-travel-insurance">I ACCEPT Travel Insurance.</option>&#13;
			<option label="I DECLINE Travel Insurance. I understand that this could result in the loss of ALL of my travel costs." value="i-decline-travel-insurance-i-understand-that-this-could-result-in-the-loss-of-all-of-my-travel-costs">I DECLINE Travel Insurance. I understand that this could result in the loss of ALL of my travel costs.</option>&#13;
		</field>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>

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By signing below, I authorize Code Fun Travel to charge the credit card provided herein.

** The charge will appear on your credit card statement as PAYPALTRAVEL AGENT **

** You may receive a simple email receipt from PAYPAL listing a payment to OUTSIDEAGENTS **

**Please bear in mind that any disputes by a client on a service fee charge will incur a $35 – $75 fee for each dispute. **

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