Share your information with Samantha Summers

Samantha Summers

Breakthrough Travel Co

<html>
  <body>
    <form-template>&#13;
	<fields>&#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="checkbox-group" label="Where would you like to travel?" name="where-would-you-like-to-travel" other="true">&#13;
			<option label="Walt Disney World in Florida" value="walt-disney-world-in-florida">Walt Disney World in Florida</option>&#13;
			<option label="Disneyland in California" value="disneyland-in-california">Disneyland in California</option>&#13;
			<option label="Universal Orlando" value="universal-orlando">Universal Orlando</option>&#13;
			<option label="Universal Hollywood" value="universal-hollywood">Universal Hollywood</option>&#13;
			<option label="Disney Cruise Line" value="disney-cruise-line">Disney Cruise Line</option>&#13;
			<option label="Other Cruise Line" value="other-cruise-line">Other Cruise Line</option>&#13;
			<option label="Other Destination" value="other-destination">Other Destination</option>&#13;
		</field>&#13;
		<field type="text" label="What are your preferred travel dates?" name="what-are-your-preferred-travel-dates" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Who is in your travel party? (Number of adults and children under 18, with ages of children listed please)" name="who-is-in-your-travel-party-number-of-adults-and-children-under-18-with-ages-of-children-listed-please" subtype="text" className="form-control"/>&#13;
		<field type="checkbox-group" label="What is the budget range for your trip?" name="what-is-the-budget-range-for-your-trip">&#13;
			<option label="&lt;$3000" value="3000">&lt;$3000</option>&#13;
			<option label="$3000-$5000" value="30005000">$3000-$5000</option>&#13;
			<option label="$5000-$10,000" value="500010000">$5000-$10,000</option>&#13;
			<option label="$10,000+" value="10000">$10,000+</option>&#13;
			<option label="Other" value="other">Other</option>&#13;
		</field>&#13;
		<field type="checkbox-group" label="Do any of these discounts apply to you?&amp;nbsp;" name="do-any-of-these-discounts-apply-to-you-">&#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="Florida Resident " value="florida-resident-">Florida Resident </option>&#13;
			<option label="California Resident " value="california-resident-">California Resident </option>&#13;
			<option label="Annual Pass Holder " value="annual-pass-holder-">Annual Pass Holder </option>&#13;
			<option label="Canadian Resident " value="canadian-resident-">Canadian Resident </option>&#13;
			<option label="Disney+ Subscriber " value="disney-subscriber-">Disney+ Subscriber </option>&#13;
		</field>&#13;
		<field type="text" label="Is there anything else you would like me to know?&amp;nbsp;" name="is-there-anything-else-you-would-like-me-to-know-" subtype="text" className="form-control"/>&#13;
		<field type="text" label="How did you hear about me?&amp;nbsp;" name="how-did-you-hear-about-me-" subtype="text" className="form-control"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>