Share your information with Shannon Fuhs

Shannon Fuhs

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h2" label="Traveler Contact Information"/>&#13;
		<field type="text" required="true" label="First name" placeholder="Legal Name that matches government ID" 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" label="Preferred name (nickname)" name="preferred-name" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Primary email address" name="email" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Primary phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h2" label="&amp;nbsp;Traveler Address"/>&#13;
		<field type="text" required="true" 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" 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="date" required="true" label="Birthday" name="birthday" className="form-control"/>&#13;
		<field type="date" label="Wedding anniversary" name="wedding-anniversary" className="form-control"/>&#13;
		<field type="header" subtype="h2" label="Passport Info"/>&#13;
		<field type="text" label="Full name as it appears on passport" name="passport-name" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Passport number" name="passport-number" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Country of issue" name="passport-country-of-issue" subtype="text" className="form-control"/>&#13;
		<field type="date" label="Date of issue" name="passport-date-of-issue" className="form-control"/>&#13;
		<field type="date" label="Date of expiration" name="passport-date-of-expiration" className="form-control"/>&#13;
		<field type="radio-group" label="Gender" 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" 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" label="Citizenship" name="citizenship" subtype="text" className="form-control"/>&#13;
		<field type="file" label="Photo of passport ID page" name="passport_photo" subtype="file" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="Emergency Contact Information"/>&#13;
		<field type="text" label="Name" name="name" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Phone&amp;nbsp;" name="phone-" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Relationship to you&amp;nbsp;" name="relationship-to-you-" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="Additional Information"/>&#13;
		<field type="paragraph" subtype="p" label="Roommate Arrangements"/>&#13;
		<field type="text" label="I would like the following roommate." name="i-would-like-the-following-roommate" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" label="Additional options" name="additional-options">&#13;
			<option label="Please match me with a roommate (same gender)for this trip. " value="please-match-me-with-a-roommate-same-genderfor-this-trip-">Please match me with a roommate (same gender)for this trip. </option>&#13;
			<option label="I prefer my own room for the additional $350. " value="i-prefer-my-own-room-for-the-additional-350-">I prefer my own room for the additional $350. </option>&#13;
		</field>&#13;
		<field type="textarea" label="To ensure we have the best experience possible, is there anything you&#39;d like to share that might impact your travels? This could include health concerns, accessibility needs, dietary restrictions, or anything else you&#39;d like us to be aware of. Feel free to reach out privately if you prefer. Your comfort and safety are our priority&amp;nbsp;" name="to-ensure-we-have-the-best-experience-possible-is-there-anything-youd-like-to-share-that-might-impact-your-travels-this-could-include-health-concerns-accessibility-needs-dietary-restrictions-or-anything-else-youd-like-us-to-be-aware-of-feel-free-to-reach-out-privately-if-you-prefer-your-comfort-and-safety-are-our-priority-" className="form-control"/>&#13;
		<field type="textarea" label="&amp;nbsp;Do you have a home parish you&#39;d like to share with us?&amp;nbsp;" name="-do-you-have-a-home-parish-youd-like-to-share-with-us-" className="form-control"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>