Share your information with Likisha Rodriguez

Likisha Rodriguez

Travels by Likisha

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  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h2" label="Contact Information"/>&#13;
		<field type="select" required="true" label="Which &quot;Wine Me&quot; Experience did you book?" name="which-wine-me-experience-did-you-book" className="form-control">&#13;
			<option label="Wine Me Experience ($280)" value="wine-me-experience-280">Wine Me Experience ($280)</option>&#13;
			<option label="VIP Wine Me Experience ($425)" value="vip-wine-me-experience-425">VIP Wine Me Experience ($425)</option>&#13;
			<option label="Wine Me Escape Weekend ($555)" value="wine-me-escape-weekend-555">Wine Me Escape Weekend ($555)</option>&#13;
			<option label="** Early Bird ** Wine Me Experience" value="-early-bird-wine-me-experience">** Early Bird ** Wine Me Experience</option>&#13;
		</field>&#13;
		<field type="text" required="true" label="First name" name="first-name" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Middle name" name="middle-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="Birthdate" name="birthdate" 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="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="header" subtype="h1" label="GUEST DETAILS"/>&#13;
		<field type="text" label="Preferred name (nickname)" name="preferred-name" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="Gender" name="gender">&#13;
			<option label="Female" value="female">Female</option>&#13;
			<option label="Male" value="male">Male</option>&#13;
			<option label="Other" value="other">Other</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="T-Shirt Size" name="tshirt-size" other="true">&#13;
			<option label="X-Small" value="xsmall">X-Small</option>&#13;
			<option label="Small" value="small">Small</option>&#13;
			<option label="Medium" value="medium">Medium</option>&#13;
			<option label="Large" value="large">Large</option>&#13;
			<option label="X-Large" value="xlarge">X-Large</option>&#13;
			<option label="2XL" value="2xl">2XL</option>&#13;
			<option label="3XL" value="3xl">3XL</option>&#13;
			<option label="4XL" value="4xl">4XL</option>&#13;
		</field>&#13;
		<field type="text" label="Number of Guests (how many guest will be traveling with you)" name="number-of-guests-how-many-guest-will-be-traveling-with-you" subtype="text" className="form-control"/>&#13;
		<field type="textarea" label="Name of all Guest Traveling Together (we will do our best to sit you close together)" name="name-of-all-guest-traveling-together-we-will-do-our-best-to-sit-you-close-together" className="form-control"/>&#13;
		<field type="header" subtype="h2" label="Travel Preferences"/>&#13;
		<field type="radio-group" required="true" label="Are you Celebrating a Special Day/Moment" name="are-you-celebrating-a-special-daymoment">&#13;
			<option label="Birthday" value="birthday">Birthday</option>&#13;
			<option label="Anniversary" value="anniversary">Anniversary</option>&#13;
			<option label="Girl's Trip" value="girls-trip">Girl's Trip</option>&#13;
			<option label="Bae-vacation" value="baevacation">Bae-vacation</option>&#13;
			<option label="Just a Lover of Luxury &amp; Wine" value="just-a-lover-of-luxury-wine">Just a Lover of Luxury &amp; Wine</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="Seat preference" name="seat-preference">&#13;
			<option label="Window" value="window">Window</option>&#13;
			<option label="Aisle" value="aisle">Aisle</option>&#13;
			<option label="Opposite Aisle" value="opposite aisle">Opposite Aisle</option>&#13;
		</field>&#13;
		<field type="radio-group" label="Bed preference (Only if you Booked &quot;The Wine Me Weekend Escape&quot;" name="bed-preference">&#13;
			<option label="King" value="king">King</option>&#13;
			<option label="2 Double/Queen" value="2-double-queen">2 Double/Queen</option>&#13;
		</field>&#13;
		<field type="checkbox-group" label="What kind of vibe are you looking for?" description="Check all that apply." name="vibe-preference">&#13;
			<option label="Romantic" value="romantic">Romantic</option>&#13;
			<option label="Rest and relaxation" value="rest-and-relaxation">Rest and relaxation</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="Local culture" value="local-culture">Local culture</option>&#13;
			<option label="Food and wine" value="food-wine">Food and wine</option>&#13;
		</field>&#13;
		<field type="textarea" label="Please use this area to make us aware of any additional information or preferences. (ie; medical concerns, dietary preferences...)" name="please-use-this-area-to-make-us-aware-of-any-additional-information-or-preferences-ie-medical-concerns-dietary-preferences" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="“I understand my deposit is non-refundable and remaining balance is required before the experience date.”"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>