Share your information with Neneh Brewah

Neneh Brewah

Goshen Legacy Travel & Tour

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    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h2" label="Full name"/>&#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="date" required="true" label="Date of Birth" name="date-of-birth" 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="radio-group" required="true" label="Gender" name="gender">&#13;
			<option label="Male" value="male">Male</option>&#13;
			<option label="Female" value="female">Female</option>&#13;
		</field>&#13;
		<field type="textarea" required="true" label="What city/state/country are you traveling from?" name="what-city-and-state-are-you-traveling-from" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="What retreat dates are you interested in?" name="travel-information-">&#13;
			<option label="January 5-9 2026" value="january-59-2026">January 5-9 2026</option>&#13;
			<option label="April 6-10 2026" value="april-610-2026">April 6-10 2026</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="Attendees" name="how-many-attendees">&#13;
			<option label="1 Solo) " value="1-solo-">1 Solo) </option>&#13;
			<option label="2 (Group/Couple)" value="2-groupcouple">2 (Group/Couple)</option>&#13;
		</field>&#13;
		<field type="text" required="true" label="What Inspired You about this Retreat?" name="what-inspired-you-about-this-retreat" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="What personal challenges are you currently facing (e.g., stress, anxiety, burnout, trauma, life transitions)?" name="are-you-celebrating-a-special-occasion-during-the-trip-of-interest-ie-birthday" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="Do you Need Passport/Visa Assistance?" name="do-you-need-passportvisa-assistance">&#13;
			<option label="Yes-I need assistance with both " value="yesi-need-assistance-with-both-">Yes-I need assistance with both </option>&#13;
			<option label="I have Passport, but need visa assistance" value="i-have-passport-but-need-visa-assistance">I have Passport, but need visa assistance</option>&#13;
			<option label="No" value="no">No</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="How did you hear about Goshen Legacy Travel &amp;amp; Tour?" name="how-did-you-hear-about-goshen-legacy-travel-tour">&#13;
			<option label="Instagram" value="instagram">Instagram</option>&#13;
			<option label="Facebook" value="facebook">Facebook</option>&#13;
			<option label="Tiktok" value="tiktok">Tiktok</option>&#13;
			<option label="Other/Word of Mouth" value="otherword-of-mouth">Other/Word of Mouth</option>&#13;
		</field>&#13;
		<field type="header" subtype="h1" label="Next Steps: Once we receive your form, a retreat coordinator will contact you with payment details, detailed retreat info, travel guidance and preparation resources!"/>&#13;
	</fields>&#13;
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  </body>
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