<html> <body> <form-template> <fields> <field type="header" subtype="h2" label="Contact Information"/> <field type="header" subtype="h1" label="You can complete the entire form but only the fields with the Red * are required fields."/> <field type="text" label="Prefix" name="prefix" subtype="text" className="form-control"/> <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" name="last-name" subtype="text" className="form-control"/> <field type="text" label="Suffix" name="suffix" subtype="text" className="form-control"/> <field type="text" label="Preferred name (nickname)" name="preferred-name" subtype="text" className="form-control"/> <field type="text" required="true" label="Primary email address" name="email" subtype="text" className="form-control"/> <field type="text" required="true" label="Phone number" name="phone-number" subtype="text" className="form-control"/> <field type="date" required="true" label="Date of birth" name="birthday" className="form-control"/> <field type="header" subtype="h2" label="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" label="Country" name="address-country" subtype="text" className="form-control"/> <field type="checkbox-group" required="true" label="Are you aware that flights not included?" name="are-you-aware-that-flights-not-included"> <option label="Yes" value="yes">Yes</option> <option label="No" value="no">No</option> </field> <field type="checkbox-group" required="true" label="Do you need assistance booking airfare" name="do-you-need-assistance-booking-airfare"> <option label="Yes" value="yes">Yes</option> <option label="No" value="no">No</option> </field> <field type="text" label="Departure airport?" name="departure-airport" subtype="text" className="form-control"/> <field type="date" label="Departure Date" name="departure-date" className="form-control"/> <field type="date" label="Return Date" name="return-date" 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> </field> <field type="header" subtype="h2" label="Travel Preferences"/> <field type="radio-group" label="Seat preference" name="seat-preference"> <option label="Window" value="window">Window</option> <option label="Aisle" value="aisle">Aisle</option> <option label="Opposite Aisle" value="opposite aisle">Opposite Aisle</option> </field> <field type="radio-group" required="true" label="Bed preference" name="bed-preference"> <option label="Room with a friend or spouse - 1 bed" value="room-with-a-friend-or-spouse-1-bed">Room with a friend or spouse - 1 bed</option> <option label="Room with a friend or spouse - 2 beds" value="room-with-a-friend-or-spouse-2-beds">Room with a friend or spouse - 2 beds</option> <option label="Pair with a roommate - 2 beds" value="pair-with-a-roommate-2-beds">Pair with a roommate - 2 beds</option> <option label="Private single room - 1 bed (extra cost Single supplement)" value="private-single-room-1-bed-extra-cost-single-supplement">Private single room - 1 bed (extra cost Single supplement)</option> </field> <field type="text" label="Roommate's Name (if applicable or say "Please Assign Me One"" name="roommates-name-if-applicable-or-say-please-assign-me-one" subtype="text" className="form-control"/> <field type="date" label="Roommate's Date of Birth" name="roommates-date-of-birth" className="form-control"/> <field type="checkbox-group" label="Would you like to be invoiced separately from your roommate?" name="would-you-like-to-be-invoiced-separately-from-your-roommate"> <option label="Yes" value="yes">Yes</option> <option label="No" value="no">No</option> </field> <field type="textarea" required="true" label="Any health or medical issues (please share any allergies or important medication we should be aware of)" name="any-health-or-medical-issues-please-share-any-allergies-or-important-medication-we-should-be-aware-of" className="form-control"/> <field type="text" label="Special Requests or Dietary Restrictions:&nbsp;" name="special-requests-or-dietary-restrictions-" subtype="text" className="form-control"/> <field type="textarea" label="Notes to Organizer" name="notes-to-organizer" className="form-control"/> <field type="header" subtype="h1" label="Travel Insurance Waiver"/> <field type="paragraph" subtype="p" label="I have been given the option to purchase travel insurance. If I decline the offer to purchase travel protection / trip insurance. I understand that I am solely responsible for any cancellation penalties and out-of-pocket expenses incurred. I will also make my own separate travel&nbsp; medical and any other provisions in the event of an emergency while I am traveling. I also understand that I am not protected from loss in the event of any travel vendor, travel supplier or any travel-related operator default. This waiver confirms that I voluntarily decline travel insurance and travel protection insurance for the trip described above. I understand I am solely liable for all airline fees, supplier fees, and agency fees that may apply, and I hereby release Majestic Dream Vacations, LLC, its agents and suppliers from any and all liability related to the trip described above."/> <field type="checkbox-group" required="true" label="Choose an option (RECOMMENDED)" name="would-you-like-travel-insurance-highly-recommended"> <option label="Yes I ACCEPT and will purchase travel insurance" value="yes-i-accept-and-will-purchase-travel-insurance">Yes I ACCEPT and will purchase travel insurance</option> <option label="No I DECLINE and will not purchase of travel insurance" value="no-i-decline-and-will-not-purchase-of-travel-insurance">No I DECLINE and will not purchase of travel insurance</option> </field> <field type="header" subtype="h1" label="Terms and Conditions"/> <field type="paragraph" subtype="p" label="By signing this,&nbsp;I authorize Majestic Dream Vacations, LLC to charge the credit card or bank account indicated on this invoice for the noted amount on today's date. This payment is for the services described on the invoice. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company, so long as the transaction corresponds to the terms indicated on this invoice. I assume full responsibility for said charges, and agree to honor and abide by the terms of this payment. I acknowledge and accept Majestic Dream Vacations, LLC Terms and Conditions."/> </fields> </form-template> </body> </html>
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