Share your information with Marcy Middleman

Marcy Middleman

Barely Packed Travel w/ WorldVia

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    <form-template>&#13;
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		<field type="header" subtype="h3" label="Your Next Adventure Awaits!"/>&#13;
		<field type="paragraph" subtype="p" label="Whether you&#39;re dreaming of white sand beaches, magical moments at Disney, cruising the high seas or heading somewhere in between, I&#39;ve got you covered!"/>&#13;
		<field type="paragraph" subtype="p" label="My goal is to make your vacation unforgettable, and to do that I&#39;ll need a little information to get started so i can make personalized recommendations just for you."/>&#13;
		<field type="paragraph" subtype="p" label="As your certified travel planner, I am here to help you plan and book your trips, tickets, hotels, tours and more. When you book through me, my services are 100% included. Travel providers pay me to take the stress off of you so you can just relax &amp;amp; enjoy! So, let&#39;s get you on that next adventure!"/>&#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="text" required="true" label="Email" name="email" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="Where would you like to travel to?"/>&#13;
		<field type="radio-group" label="Radio Group" name="radio-group-1767393052366">&#13;
			<option label="Walt Disney World (Florida)" value="walt-disney-world-florida">Walt Disney World (Florida)</option>&#13;
			<option label="Disneyland (California)" value="disneyland-california">Disneyland (California)</option>&#13;
			<option label="Disney Cruise Line" value="disney-cruise-line">Disney Cruise Line</option>&#13;
			<option label="Universal Studios (Florida)" value="universal-studios-florida">Universal Studios (Florida)</option>&#13;
			<option label="Royal Caribbean Cruise" value="royal-caribbean-cruise">Royal Caribbean Cruise</option>&#13;
			<option label="Other Cruise Line" value="other-cruise-line">Other Cruise Line</option>&#13;
			<option label="All Inclusive Resort" value="all-inclusive-resort">All Inclusive Resort</option>&#13;
			<option label="Other Destination" value="other-destination">Other Destination</option>&#13;
		</field>&#13;
		<field type="header" subtype="h1" label="Travel Dates (whether you have exact dates in mind or you need some help deciding let me know as much as you can and we&#39;ll chat about your best options)"/>&#13;
		<field type="textarea" label="Text Area" name="textarea-1767393342630" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="Who all is traveling in your party? ** Please include # of adults and # of children (please also include kids ages at time of travel)"/>&#13;
		<field type="textarea" label="Text Area" name="textarea-1767394566187" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="What is your budget?"/>&#13;
		<field type="radio-group" label="Radio Group" name="radio-group-1767393449942">&#13;
			<option label="$1500 to $3000" value="1500-to-3000">$1500 to $3000</option>&#13;
			<option label="$3000 to $5000" value="3000-to-5000">$3000 to $5000</option>&#13;
			<option label="$5000 to $7000" value="5000-to-7000">$5000 to $7000</option>&#13;
			<option label="$7500 to $10,000" value="7500-to-10000">$7500 to $10,000</option>&#13;
			<option label="Other" value="other">Other</option>&#13;
		</field>&#13;
		<field type="header" subtype="h1" label="Do any of these discounts apply?"/>&#13;
		<field type="radio-group" label="Radio Group" name="radio-group-1767393547990">&#13;
			<option label="Active, Retired, or 100% Disabled Military" value="active-retired-or-100-disabled-military">Active, Retired, or 100% Disabled Military</option>&#13;
			<option label="Disney Chase Visa Card Holder" value="disney-chase-visa-card-holder">Disney Chase Visa Card Holder</option>&#13;
			<option label="Disney+ Subscriber" value="disney-subscriber">Disney+ Subscriber</option>&#13;
			<option label="Annual Pass Holder" value="annual-pass-holder">Annual Pass Holder</option>&#13;
			<option label="Florida Resident" value="florida-resident">Florida Resident</option>&#13;
			<option label="California Resident" value="california-resident">California Resident</option>&#13;
		</field>&#13;
		<field type="header" subtype="h1" label="Are you celebrating anything special?"/>&#13;
		<field type="text" label="Text Field" name="text-1767489644475" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="Would you like me to know anything else about your trip?"/>&#13;
		<field type="textarea" label="Text Area" name="textarea-1767393700711" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="How did you hear about me?"/>&#13;
		<field type="text" label="Text Field" name="text-1767393748838" subtype="text" className="form-control"/>&#13;
	</fields>&#13;
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