Share your information with Andrea Cipcic

Andrea Cipcic

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="paragraph" subtype="p" label="Let me know a little bit about what you are looking for in your vacation."/>&#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" required="true" label="Phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="select" required="true" label="Travel Destination" description="Select from the list" placeholder="Choose your destination" name="travel-destination" className="form-control">&#13;
			<option label="Walt Disney World (Orlando, FL)" value="walt-disney-world-orlando-fl">Walt Disney World (Orlando, FL)</option>&#13;
			<option label="Disneyland (Anaheim, CA)" value="disneyland-anaheim-ca">Disneyland (Anaheim, CA)</option>&#13;
			<option label="Universal Resort (Orlando, FL)" value="universal-resort-orlando-fl">Universal Resort (Orlando, FL)</option>&#13;
			<option label="Universal Studios Hollywood (CA)" value="universal-studios-hollywood-ca">Universal Studios Hollywood (CA)</option>&#13;
			<option label="Disney's Aulani Resort (Hawaii)" value="disneys-aulani-resort-hawaii">Disney's Aulani Resort (Hawaii)</option>&#13;
		</field>&#13;
		<field type="date" required="true" label="When would you like to depart?" description="This just gives me a general idea of when you like to go; it can be changed later." name="starting-at" className="form-control"/>&#13;
		<field type="date" required="true" label="When would you like to return?" description="This just gives me a general idea of when you like to return; it can be changed later." name="ending-at" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="What is your budget for all travelers?" description="This just gives me a general starting point and can always be changed later." name="budget">&#13;
			<option label="$2,500 to $5,000" value="2500-to-5000">$2,500 to $5,000</option>&#13;
			<option label="$5,000 to $7,000" value="5000-to-7000">$5,000 to $7,000</option>&#13;
			<option label="$7,000 to $9,000" value="7000-to-9000">$7,000 to $9,000</option>&#13;
			<option label="$9,000+" value="9000">$9,000+</option>&#13;
		</field>&#13;
		<field type="text" required="true" label="How many adult travelers?" name="number-of-travelers" subtype="text" className="form-control"/>&#13;
		<field type="textarea" required="true" label="First and Last Name of all adults" name="first-and-last-name-of-all-adults" className="form-control"/>&#13;
		<field type="text" required="true" label="How many child travelers?" name="text-1739413236800" subtype="text" className="form-control"/>&#13;
		<field type="textarea" required="true" label="First and Last name of children (please include ages at the time of travel)" name="first-and-last-name-of-children-please-include-ages-at-the-time-of-travel" className="form-control"/>&#13;
		<field type="checkbox-group" label="What are you interested in booking? (Select all that apply)" name="what-are-you-interested-in-booking-select-all-that-apply">&#13;
			<option label="Resort Hotel" value="resort-hotel">Resort Hotel</option>&#13;
			<option label="Theme Park Tickets" value="theme-park-tickets">Theme Park Tickets</option>&#13;
			<option label="Dining Plan" value="dining-plan">Dining Plan</option>&#13;
			<option label="I'm not sure...tell me what I need!" value="im-not-suretell-me-what-i-need">I'm not sure...tell me what I need!</option>&#13;
		</field>&#13;
		<field type="checkbox-group" required="true" label="Do you qualify for any discounts? (Select all that apply)" name="do-you-qualify-for-any-discounts">&#13;
			<option label="Disney+ Subscriber" value="disney-subscriber">Disney+ Subscriber</option>&#13;
			<option label="Disney Visa Cardholder" value="disney-visa-cardholder">Disney Visa Cardholder</option>&#13;
			<option label="Florida Resident" value="florida-resident">Florida Resident</option>&#13;
			<option label="Annual Passholder" value="annual-passholder">Annual Passholder</option>&#13;
			<option label="Active, Retired or 100% Disabled Military" value="active-retired-or-100-disabled-military">Active, Retired or 100% Disabled Military</option>&#13;
		</field>&#13;
		<field type="checkbox-group" label="Are you celebrating anything?" description="Select any that apply" name="are-you-celebrating-anything">&#13;
			<option label="Birthday" value="birthday">Birthday</option>&#13;
			<option label="Anniversary" value="anniversary">Anniversary</option>&#13;
			<option label="Graduation" value="graduation">Graduation</option>&#13;
			<option label="Honeymoon" value="honeymoon">Honeymoon</option>&#13;
			<option label="First Visit" value="first-visit">First Visit</option>&#13;
			<option label="Personal Milestone" value="personal-milestone">Personal Milestone</option>&#13;
		</field>&#13;
		<field type="textarea" label="What else would you like me to know?" description="What else would you like me to know about your travelers  budget and/or travel preferences?" name="notes" className="form-control"/>&#13;
		<field type="text" label="How did you hear about me?" name="how-did-you-hear-about-me" subtype="text" className="form-control"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>