<form-template>
	<fields>
		<field type="header" subtype="h2" label="Ortensia Blu Travel Adventures Africa November 1-13, 2022&amp;nbsp; Registration" className="text-center"/>
		<field type="header" subtype="h2" label="Guest #1 Information"/>
		<field type="text" required="true" label="First name" name="first-name" subtype="text" className="form-control"/>
		<field type="text" label="Middle name" name="middle-name" subtype="text" className="form-control"/>
		<field type="text" required="true" label="Last name" description="Enter suffix after last name  if applicable" name="last-name" subtype="text" className="form-control"/>
		<field type="header" subtype="h2" label="Guest #1 Address"/>
		<field type="text" required="true" label="Line 1" name="address-line-1" subtype="text" className="form-control"/>
		<field type="text" label="Line 2" name="address-line-2" subtype="text" className="form-control"/>
		<field type="text" required="true" label="City" name="address-city" subtype="text" className="form-control"/>
		<field type="text" required="true" label="State" name="address-state" subtype="text" className="form-control"/>
		<field type="text" required="true" label="Zip" name="address-zip" subtype="text" className="form-control"/>
		<field type="text" required="true" label="Country" name="address-country" subtype="text" className="form-control"/>
		<field type="text" required="true" label="Email" name="email" subtype="text" className="form-control"/>
		<field type="text" required="true" label="Contact Number" name="phone-number" subtype="text" className="form-control"/>
		<field type="date" required="true" label="DOB" name="birthday" className="form-control"/>
		<field type="header" subtype="h2" label="Guest #1 Passport Info"/>
		<field type="text" required="true" label="Full name as it appears on passport" name="passport-name" subtype="text" className="form-control"/>
		<field type="text" required="true" label="Passport number" name="passport-number" subtype="text" className="form-control"/>
		<field type="text" required="true" label="Country of issue" name="passport-country-of-issue" subtype="text" className="form-control"/>
		<field type="date" required="true" label="Date of issue" name="passport-date-of-issue" className="form-control"/>
		<field type="date" required="true" label="Date of expiration" name="passport-date-of-expiration" className="form-control"/>
		<field type="radio-group" required="true" label="Gender" name="gender">
			<option label="F" value="female">F</option>
			<option label="M" value="male">M</option>
		<option label="X" value="other">X</option>
		</field>
		<field type="text" required="true" label="Place of birth" name="place-of-birth" subtype="text" className="form-control"/>
		<field type="text" required="true" label="Nationality" name="nationality" subtype="text" className="form-control"/>
		<field type="text" required="true" label="Citizenship" name="citizenship" subtype="text" className="form-control"/>
		<field type="header" subtype="h2" label="Guest #2 Information"/>
		<field type="text" label="Guest #2 First name" name="text-1519983986316" subtype="text" className="form-control"/>
		<field type="text" label="Guest #2 Middle name" name="text-1519984023779" subtype="text" className="form-control"/>
		<field type="text" label="Guest #2 Last name" description="Enter suffix after last name  if applicable" name="text-1519984039066" subtype="text" className="form-control"/>
		<field type="header" subtype="h2" label="Guest #2 Address"/>
		<field type="text" label="Guest #2 Line 1" name="address-line-1-guest-2" subtype="text" className="form-control"/>
		<field type="text" label="Line 2" name="address-line-2-guest-2" subtype="text" className="form-control"/>
		<field type="text" label="Guest #2 City" name="address-city-guest-2" subtype="text" className="form-control"/>
		<field type="text" label="Guest #2 State" name="address-state-guest-2" subtype="text" className="form-control"/>
		<field type="text" label="Guest #2 Zip Code" name="address-zip-guest-2" subtype="text" className="form-control"/>
		<field type="text" label="Guest #2 Country" name="address-country-guest-2" subtype="text" className="form-control"/>
		<field type="text" label="Guest #2 Email" name="email-guest-2" subtype="text" className="form-control"/>
		<field type="text" label="Guest #2 Contact number" name="contact-number" subtype="text" className="form-control"/>
		<field type="date" label="Guest #2 DOB" name="dob" className="form-control"/>
		<field type="textarea" label="Text Area" name="textarea-1574777920331" value="Guest # 2 Passport Info" subtype="textarea" className="form-control"/>
		<field type="text" label="Guest #2 Full name as it appears on passport" name="guest-2-full-name-as-it-appears-on-passport" subtype="text" className="form-control"/>
		<field type="text" label="Guest #2 Passport number" name="guest-2-passport-number" subtype="text" className="form-control"/>
		<field type="text" label="Guest #2 Country of Issue" name="guest-2-country-of-issue" subtype="text" className="form-control"/>
		<field type="text" label="Guest #2 Date of Issue" name="guest-2-date-of-issue" subtype="text" className="form-control"/>
		<field type="text" label="Guest #2 Date of Expiration" name="guest-2-date-of-expiration" subtype="text" className="form-control"/>
		<field type="radio-group" label="Guest #2 Gender" name="guest-2-gender">
			<option label="F" value="f">F</option>
			<option label="M" value="m">M</option>
		</field>
		<field type="text" label="Guest #2 Place of Birth" name="guest-2-place-of-birth" subtype="text" className="form-control"/>
		<field type="text" label="Guest #2 Nationality" name="guest-2-nationality" subtype="text" className="form-control"/>
		<field type="text" label="Guest #2 Citizenship" name="guest-2-citizenship" subtype="text" className="form-control"/>
		<field type="checkbox-group" required="true" label="Choose Room Option" description="Refer to costs above." name="choose-cabin-type">
			<option label="$10,295 per person double occupancy" value="10295-per-person-double-occupancy">$10,295 per person double occupancy</option>
			<option label="$4,995 single supplement" value="4995-single-supplement">$4,995 single supplement</option>
		</field>
		<field type="radio-group" required="true" label="Do you have any food allergies?" name="do-you-have-any-food-allergies">
			<option label="yes" value="yes">yes</option>
			<option label="no" value="no">no</option>
		</field>
		<field type="text" label="If yes, please explain:" name="loyalty-program-id-number" subtype="text" className="form-control"/>
		<field type="paragraph" subtype="p" label="We strongly recommend that you purchase travel insurance to protect the cost of your travel investment and to cover any unforeseen medical expenses. Ortensia Blu offers travel insurance through Travel Insured. Additional insurance can be purchased to cover any other travel expenses."/>
		<field type="checkbox-group" required="true" label="Do you want to purchase travel insurance?" description="Must include VPP cost at time of deposit" name="do-you-need-vacation-protection">
			<option label="Yes" value="yes">Yes</option>
			<option label="No" value="no">No</option>
		</field>
		<field type="text" required="true" label="Emergency Contact Name Guest #1" name="emergency-contact-name" subtype="text" className="form-control"/>
		<field type="text" required="true" label="Emergency Contact Phone Number Guest #1" name="emergency-contact-phone-number" subtype="text" className="form-control"/>
		<field type="text" label="Emergency Contact Name Guest #2" placeholder="ex: (555) 555-1234" name="details-emergency-contact-phone" subtype="text" className="form-control"/>
		<field type="text" label="Emergency Contact Phone Guest #2" placeholder="ex: (555) 555-1234" name="text-1519983857619" subtype="text" className="form-control"/>
		<field type="header" subtype="h2" label="Additional Info"/>
		<field type="header" subtype="h3" label="Price includes:"/>
		<field type="paragraph" subtype="p" label="10 nights accommodations at selected hotels, daily breakfast, VIP Meet &amp;amp; Greet at Johannesburg airport, transfer to/from accommodations, all tours and meals as noted, all game drives."/>
		<field type="header" subtype="h3" label="Not included:"/>
		<field type="paragraph" subtype="p" label="International and domestic airfare, travel insurance, gratuities, KAZA Tourist Visa ($50)&amp;nbsp;"/>
		<field type="header" subtype="h3" label="Deposits, Payment and Cancellation Policy:"/>
		<field type="paragraph" subtype="p" label="A 30% per person non-refundable deposit of $3,088 paid to Hills of Africa Travel is required to reserve a space.&amp;nbsp; Final payment of $7,207 is due on August 3, 2022.&amp;nbsp; At final payment, trip costs are 100% non-refundable."/>
		<field type="header" subtype="h3" label="Other Information"/>
		<field type="paragraph" subtype="p" label="Ortensia Blu LLC is not responsible for damage, loss or theft of personal belongings. The tour is not wheelchair accessible. Unfortunately, Ortensia Blu LLC is unable to provide travelers with individual assistance or special accommodations for walking, dining, getting on or off vehicles, or other personal needs."/>
		<field type="paragraph" subtype="p"/>
	</fields>
</form-template>

TERMS AND CONDITIONS

This notice constitutes part of your contract for travel related services. Gifted Travel Network, and Ortensia Blu LLC (dba Ortensia Blu Travel Adventures) is acting as a mere agent for suppliers (identified on the accompanying documents) in selling travel related services, or in accepting reservations or bookings for services that are not directly supplied by this travel agency (such as air and ground transportation, hotel accommodations, cruises, etc.). Ortensia Blu LLC (dba Ortensia Blu Travel Adventures) therefore, shall not be responsible for breach of contract or any intentional or careless actions or omissions on part such suppliers, which result in any loss, damage, delay, or injury to you or your companions or group members. Unless the term "guaranteed" is specifically stated in writing on your tickets, invoice, or reservation itinerary, we do not guarantee any of such suppliers' rates, bookings, reservations, connections, scheduling, or handling of personal effects. Travel agent shall not be responsible for any injuries, damages, or losses caused to any traveler in connection with activities, social or labor unrest, mechanical or construction failures or difficulties, diseases, laws, climatic conditions, abnormal conditions or developments, or any other actions, omissions, conditions outside the travel agent's control. Traveler assumes complete and full responsibility and hereby releases the agent from, any duty of checking and verifying any and all passport, visa, vaccination, or other entry requirements of each destination, and all safety and security of such destinations, during the length of the proposed travel.

By signing below and submitting this form, you acknowledge that you are hiring us to plan and organize your trip, and that you have read and agree to our Terms and Conditions of booking, which are located at https://ortensiablutraveladventures.com/service-terms-conditions/

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