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Janie Mancha

White Glove Destinations

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    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h2" label="El Salvador Group Trip Application"/>&#13;
		<field type="header" subtype="h1" label="Travel Dates: July 14 – July 20, 2026&amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; Duration: 7 Days/ 6 Nights&amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp; Rate: $1,870 per person (based on double occupancy)&amp;nbsp;"/>&#13;
		<field type="text" label="Prefix" name="prefix" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="First name" name="first-name" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Middle name" name="middle-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="text" label="Suffix" name="suffix" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Preferred name" name="preferred-name" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Email" name="email" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h2" label="Address"/>&#13;
		<field type="text" required="true" label="Line 1" name="address-line-1" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Line 2" name="address-line-2" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="City" name="address-city" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="State" name="address-state" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" 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="Phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="Travel Details"/>&#13;
		<field type="radio-group" required="true" label="Room Preference:" name="radio-group-1774317696840">&#13;
			<option label="Double Occupancy (I have a roommate)" value="double-occupancy-i-have-a-roommate">Double Occupancy (I have a roommate)</option>&#13;
			<option label="Double Occupancy (Please pair me with a roommate)" value="double-occupancy-please-pair-me-with-a-roommate">Double Occupancy (Please pair me with a roommate)</option>&#13;
			<option label="Single Occupancy (additional cost may apply)" value="single-occupancy-additional-cost-may-apply">Single Occupancy (additional cost may apply)</option>&#13;
		</field>&#13;
		<field type="text" label="Roommate Name (if applicable):" name="text-1774317773941" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Airport you will be departing from?" name="text-1774318486801" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="Travel Preferences &amp;amp; Notes"/>&#13;
		<field type="text" label="Do you have any dietary restrictions or allergies?" name="text-1774317822709" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Do you have any medical conditions we should be aware of?" name="text-1774317838691" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h2" label="Passport Info"/>&#13;
		<field type="text" required="true" label="Full name as it appears on passport" name="passport-name" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Passport number" name="passport-number" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Country of issue" name="passport-country-of-issue" subtype="text" className="form-control"/>&#13;
		<field type="date" required="true" label="Date of issue" name="passport-date-of-issue" className="form-control"/>&#13;
		<field type="date" required="true" label="Date of expiration" name="passport-date-of-expiration" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="Sex" name="gender">&#13;
			<option label="F" value="female">F</option>&#13;
			<option label="M" value="male">M</option>&#13;
			<option label="X" value="other">X</option>&#13;
		</field>&#13;
		<field type="text" required="true" label="Place of birth" name="place-of-birth" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Nationality" name="nationality" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Citizenship" name="citizenship" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="Payment Acknowledgment&amp;nbsp;"/>&#13;
		<field type="paragraph" subtype="p" label="By submitting this application, I understand and agree to the following: Deposit: 15% per person is due at the time of booking to secure my spot. Final Payment: Due 60 days prior to departure. Pricing is based on double occupancy. Space is limited and not guaranteed until deposit is received. I acknowledge that this is an application for the group trip to El Salvador and that submission does not guarantee my spot until confirmed and deposit is received. Once application is received and approved, you will receive a credit card authorization form for deposit to be applied. Applications must be recieved by April 10, 2026."/>&#13;
	</fields>&#13;
</form-template>
  </body>
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