Share your information with Nicole Howerton

Nicole Howerton

Wheels Up, Heels Up LLC

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h1" label="Primary Traveler Information"/>&#13;
		<field type="radio-group" required="true" 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" required="true" label="First name (as appears on passport)" name="first-name" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Last name (as appears on passport)" name="last-name" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Suffix" name="suffix" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Preferred name" name="preferred-name" subtype="text" className="form-control"/>&#13;
		<field type="date" required="true" label="Birthday" name="birthday" className="form-control"/>&#13;
		<field type="text" required="true" label="Phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="State Of Residence?" name="state-of-residence" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="Travel Preferences"/>&#13;
		<field type="clientLoyaltyPrograms" label="Travel Preferences" description="Travel Preferences" name="loyalty-program" loyalty-program-note="*** This field allows your client to enter multiple loyalty program numbers (you only need one of these per form template) ***" className="form-control"/>&#13;
		<field type="radio-group" label="Are you celebrating a special occasion for this trip?" name="are-you-celebrating-a-special-occasion-for-this-cruise" other="true">&#13;
			<option label="Birthday" value="birthday">Birthday</option>&#13;
			<option label="Anniversary" value="anniversary">Anniversary</option>&#13;
			<option label="Honeymoon" value="honeymoon">Honeymoon</option>&#13;
			<option label="Family Getaway" value="family-getaway">Family Getaway</option>&#13;
			<option label="Fun Getaway" value="fun-getaway">Fun Getaway</option>&#13;
			<option label="Retirement Celebration" value="retirement-celebration">Retirement Celebration</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="First Time Traveling?" name="first-time-cruiser">&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
			<option label="No" value="no">No</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="What is your budget for all travelers? Applicable to the hotel ONLY." name="what-is-your-budget-for-this-cruise">&#13;
			<option label="$1,500 to $2,500" value="1500-to-2500">$1,500 to $2,500</option>&#13;
			<option label="$2,500 to $4,500" value="2500-to-4500">$2,500 to $4,500</option>&#13;
			<option label="$4,500 to $6,500" value="4500-to-6500">$4,500 to $6,500</option>&#13;
			<option label="$6,500 to $8,500" value="6500-to-8500">$6,500 to $8,500</option>&#13;
			<option label="$8,500 to $10,000" value="8500-to-10000">$8,500 to $10,000</option>&#13;
			<option label="$10,000+" value="10000">$10,000+</option>&#13;
		</field>&#13;
		<field type="text" required="true" label="Email" name="email" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" label="Would you like to apply for Uplift financing with $0 down + interest free?" name="would-you-like-to-use-uplift-financing-with-0-down-interest-free-">&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
			<option label="No" value="no">No</option>&#13;
		</field>&#13;
		<field type="text" label="Destination" placeholder="Ex: The Bahamas  The Caribbean" name="sail-to" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="DATES (Departure and Return)" placeholder="Ex: April 2026 or April 20  2026" name="dates" subtype="text" className="form-control"/>&#13;
		<field type="checkbox-group" required="true" label="DURATION (for cruises or if flexible on return date)" description="For cruises or if flexible on return date" name="duration">&#13;
			<option label="2 - 5 DAYS" value="2-5-days">2 - 5 DAYS</option>&#13;
			<option label="6 - 9 DAYS" value="6-9-days">6 - 9 DAYS</option>&#13;
			<option label="10+ DAYS" value="10-days">10+ DAYS</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="Do You Need A Wheelchair, Powerchair or Scooter Accessible Cabin?" name="do-you-need-a-handicap-accessible-cabin">&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
			<option label="No" value="no">No</option>&#13;
		</field>&#13;
		<field type="checkbox-group" label="Medical" description="Wheelchair Assistance Is Only Available For Embarkation and Debarkation when Guest Isn&#39;t Bring Their Own Wheelchair" name="medical">&#13;
			<option label="WHEELCHAIR ASSISTANCE" value="wheelchair-assistance">WHEELCHAIR ASSISTANCE</option>&#13;
			<option label="DIABETIC  " value="diabetic-">DIABETIC  </option>&#13;
			<option label="COGNITIVE DISABILITIES " value="cognitive-disabilities-">COGNITIVE DISABILITIES </option>&#13;
			<option label="CONCENTRATOR  " value="concentrator-">CONCENTRATOR  </option>&#13;
			<option label="AUTISM  " value="autism-">AUTISM  </option>&#13;
			<option label="BLIND OR LOW VISION" value="blind-or-low-vision">BLIND OR LOW VISION</option>&#13;
			<option label="DEAF " value="deaf-">DEAF </option>&#13;
			<option label="ALLERGIES " value="allergies-">ALLERGIES </option>&#13;
			<option label="PREGNANT LESS 24 FULL WKS " value="pregnant-less-24-full-wks-">PREGNANT LESS 24 FULL WKS </option>&#13;
			<option label="SHARPS CONTAINER" value="sharps-container">SHARPS CONTAINER</option>&#13;
			<option label="DIALYSIS " value="dialysis-">DIALYSIS </option>&#13;
			<option label="WHEELCHAIR " value="wheelchair-">WHEELCHAIR </option>&#13;
			<option label="PREG MORE THAN 24 FULL WKS" value="preg-more-than-24-full-wks">PREG MORE THAN 24 FULL WKS</option>&#13;
			<option label="OXYGEN " value="oxygen-">OXYGEN </option>&#13;
		</field>&#13;
		<field type="checkbox-group" label="Would you like to add the following after Booking?" description="Pricing Will Be Quoted AFTER Booking Is Secured" name="would-you-like-to-add-the-following-after-booking" other="true">&#13;
			<option label="Specialty Dining" value="specialty-dining">Specialty Dining</option>&#13;
			<option label="Excursions" value="Excursions">Excursions</option>&#13;
			<option label="Travel Insurance" value="travel-insurance">Travel Insurance</option>&#13;
		</field>&#13;
		<field type="radio-group" label="How did you hear about us?" name="how-did-you-hear-about-us" other="true">&#13;
			<option label="Youtube" value="youtube">Youtube</option>&#13;
			<option label="Facebook" value="facebook">Facebook</option>&#13;
			<option label="Instagram" value="instagram">Instagram</option>&#13;
			<option label="Google" value="google">Google</option>&#13;
		</field>&#13;
		<field type="header" subtype="h1" label="TRAVEL INSURANCE"/>&#13;
		<field type="paragraph" subtype="p" label="By signing below, I understand that declining travel insurance could result in the loss of my travel cost and/or require more money to correct the situation. I also acknowledge that without insurance, there may be no way to recoup any losses, costs or expenses incurred."/>&#13;
		<field type="radio-group" required="true" label="Please choose:" name="please-choose">&#13;
			<option label="I ACCEPT Travel Insurance." value="i-accept-travel-insurance">I ACCEPT Travel Insurance.</option>&#13;
			<option label="I DECLINE Travel Insurance. I understand that this could result in the loss of ALL of my travel costs." value="i-decline-travel-insurance-i-understand-that-this-could-result-in-the-loss-of-all-of-my-travel-costs">I DECLINE Travel Insurance. I understand that this could result in the loss of ALL of my travel costs.</option>&#13;
		</field>&#13;
		<field type="paragraph" subtype="p" label="Travel Inquiry Agreement: By completing and submitting this form, you agree to a non-refundable $10 service fee for preliminary trip research. This fee is required before a personalized travel quote is provided."/>&#13;
		<field type="checkbox-group" required="true" label="What best describes your hotel preference?" name="what-best-describes-your-hotel-preference">&#13;
			<option label="Economy" value="economy">Economy</option>&#13;
			<option label="Moderate" value="moderate">Moderate</option>&#13;
			<option label="Luxury" value="luxury">Luxury</option>&#13;
			<option label="Boutique" value="boutique">Boutique</option>&#13;
			<option label="Other" value="other">Other</option>&#13;
		</field>&#13;
		<field type="checkbox-group" label="What kind of experience are you looking for?" name="what-kind-of-experience-are-you-looking-for" other="true">&#13;
			<option label="Rest and relaxation" value="rest-and-relaxation">Rest and relaxation</option>&#13;
			<option label="Cultural" value="cultural">Cultural</option>&#13;
			<option label="Off the beaten path" value="off-the-beaten-path">Off the beaten path</option>&#13;
			<option label="Party" value="party">Party</option>&#13;
			<option label="Family Friendly" value="family-friendly">Family Friendly</option>&#13;
			<option label="Food and Wine" value="food-and-wine">Food and Wine</option>&#13;
		</field>&#13;
		<field type="checkbox-group" label="What activities are you interested in?" name="what-activities-are-you-interested-in" other="true">&#13;
			<option label="Beach and Water" value="beach-and-water">Beach and Water</option>&#13;
			<option label="Casino" value="casino">Casino</option>&#13;
			<option label="Adventure Activities" value="adventure-activities">Adventure Activities</option>&#13;
			<option label="Golf or other sports" value="golf-or-other-sports">Golf or other sports</option>&#13;
			<option label="Nightlife" value="nightlife">Nightlife</option>&#13;
			<option label="Arts and Theater" value="arts-and-theater">Arts and Theater</option>&#13;
		</field>&#13;
		<field type="textarea" label="Text Area" name="textarea-1754594347546" value="Is there anything you absolutely must see or do?" className="form-control"/>&#13;
		<field type="textarea" label="Text Area" name="textarea-1754594450866" value="What else would you like me to know?" className="form-control"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>

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