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Carmen Richardson
Breakaway Travel
<html> <body> <form-template> <fields> <field type="header" subtype="h2" label="Breakaway Travel Request&nbsp;"/> <field type="paragraph" subtype="p" label="Thanks for choosing Breakaway Travel! Complete this quick form, and I’ll create a getaway made just for you. 🌍✈️&nbsp;"/> <field type="text" required="true" label="First name&nbsp;" name="first-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" required="true" label="Email" name="email" subtype="text" className="form-control"/> <field type="text" label="Phone number" name="phone-number" subtype="text" className="form-control"/> <field type="date" required="true" label="Date of Birth" name="date-of-birth" className="form-control"/> <field type="radio-group" required="true" label="Gender" name="gender"> <option label="F" value="f">F</option> <option label="M" value="m">M</option> <option label="X" value="x">X</option> </field> <field type="radio-group" required="true" label="Best Method of Contact" name="best-method-of-contact"> <option label="Phone" value="phone">Phone</option> <option label="Email" value="email">Email</option> <option label="Text" value="text">Text</option> </field> <field type="date" required="true" label="Departure Date&nbsp;" description="This gives me a general idea of when you like to go; it can be changed later." placeholder="Put 9/9/99 if flights are not needed" name="starting-at" className="form-control"/> <field type="date" required="true" label="Return Date" description="This gives me a general idea of when you like to return; it can be changed later." name="ending-at" className="form-control"/> <field type="radio-group" required="true" label="Are your dates flexible?" name="are-your-dates-flexible"> <option label="Yes" value="yes">Yes</option> <option label="No" value="no">No</option> </field> <field type="date" required="true" label="How soon are you looking to make a deposit?" name="how-soon-are-you-looking-to-make-a-deposit" className="form-control"/> <field type="radio-group" required="true" label="Please select the type of travel services you need? (U.S. destinations do not have All Inclusive Resorts)" description="ALL Inclusive indicates meals and drinks are included in price" name="vacation-options" other="true"> <option label="US Destination (Non Inclusive)" value="us-destination-non-inclusive">US Destination (Non Inclusive)</option> <option label="Hotel & Resort Only (Non Inclusive)" value="hotel-resort-only-non-inclusive">Hotel & Resort Only (Non Inclusive)</option> <option label="All Inclusive -Flights, Meals, Drinks Included (Mexico & Caribbean Destinations Only)" value="all-inclusive-flights-meals-drinks-included-mexico-caribbean-destinations-only">All Inclusive -Flights, Meals, Drinks Included (Mexico & Caribbean Destinations Only)</option> <option label="Custom International Package (Flight/Accommodations/Tours) Ex: Dubai, Paris, Bali)" value="custom-international-package-flightaccommodationstours-ex-dubai-paris-bali">Custom International Package (Flight/Accommodations/Tours) Ex: Dubai, Paris, Bali)</option> <option label="Tours/Activities Only" value="toursactivities-only">Tours/Activities Only</option> </field> <field type="text" required="true" label="Destination of Choice (Please choose only one,&nbsp; more than one will require an additional research fee)" description="Add Prefered Hotel Chain or Resort" placeholder="i.e. Vegas New York Jamaica etc.." name="destination-of-choice-please-choose-only-one-more-than-one-will-require-an-additional-research-fee" subtype="text" className="form-control"/> <field type="text" required="true" label="Number of Adults traveling?&nbsp; (Ages 17+)" description="More than 10 guests will require an additional fee" name="number-of-adults-attending" subtype="text" className="form-control"/> <field type="text" required="true" label="Number of children under Age 17 traveling ? ( Ages at time of travel)" name="number-of-kids-kids-ages-at-time-of-travel" subtype="text" className="form-control"/> <field type="text" required="true" label="Number of guest rooms needed? (max of 4 people per room for all inclusive destinations)" description="please specify if a special type of room is needed" placeholder="For 2 or more rooms please specify how many adults/children will be in each room" name="number-of-rooms-needed-max-of-3-for-all-inclusive-destinations" subtype="text" className="form-control"/> <field type="select" required="true" label="For All Inclusive Inquiries, would you like any of these amenities in your room? Why not!!&nbsp;" description="Based on Availability" name="for-all-inclusive-inquiries-would-you-like-any-of-these-amenities-in-your-room-why-not-" multiple="multiple" className="form-control"> <option label=" Standard/Gardenview" value="-standardgardenview"> Standard/Gardenview</option> <option label="Oceanfront" value="oceanfront">Oceanfront</option> <option label="Oceanview" value="oceanview">Oceanview</option> <option label="Private Pool or Swimout" value="private-pool-or-swimout">Private Pool or Swimout</option> </field> <field type="checkbox-group" required="true" label="Desired vacation experience and vibe?" description="Check all that apply." inline="true" name="vibe-preference" other="true"> <option label="All Adult Resort" value="all-adult-resort">All Adult Resort</option> <option label="Child/Family friendly resort" value="childfamily-friendly-resort">Child/Family friendly resort</option> <option label="Couples Only Resort" value="couples-only-resort">Couples Only Resort</option> <option label="LGBTQI+ friendly" value="lgbtqi-friendly">LGBTQI+ friendly</option> <option label="Destination Wedding" value="destination-wedding">Destination Wedding</option> <option label="Romantic/Intimate" value="romanticintimate">Romantic/Intimate</option> <option label="Rest & Relaxation" value="rest-relaxation">Rest & Relaxation</option> <option label="Party" value="party">Party</option> </field> <field type="radio-group" required="true" label="What type of vacation is this?" inline="true" name="what-type-of-vacation-is-this" other="true"> <option label="Celebration (Birthday, Graduation, etc..)" value="celebration-birthday-graduation-etc">Celebration (Birthday, Graduation, etc..)</option> <option label="Anniversary /Honeymoon/Engagement" value="anniversary-honeymoonengagement">Anniversary /Honeymoon/Engagement</option> <option label="Family Vacation " value="family-vacation-">Family Vacation </option> <option label="Solo Vacation" value="solo-vacation">Solo Vacation</option> <option label="Guys/Girls Trip" value="guysgirls-trip">Guys/Girls Trip</option> </field> <field type="radio-group" required="true" label="Do all travelers have a valid passport?&nbsp;" name="do-you-have-a-passport"> <option label="Yes" value="yes">Yes</option> <option label="No" value="no">No</option> <option label="Waiting for Arrival" value="waiting-for-arrival">Waiting for Arrival</option> <option label="N/A for this Vacation" value="na-for-this-vacation">N/A for this Vacation</option> </field> <field type="radio-group" label="Have you received the COVID-19 Vaccination?" name="have-you-received-the-covid19-vaccination"> <option label="Yes" value="yes">Yes</option> <option label="No" value="no">No</option> </field> <field type="radio-group" required="true" label="What best describes your hotel preference?" name="hotel-preference" other="true"> <option label="Economy" value="value">Economy</option> <option label="Moderate" value="moderate">Moderate</option> <option label="Luxury" value="luxury">Luxury</option> <option label="Vacation Home" value="vacation-home">Vacation Home</option> </field> <field type="checkbox-group" required="true" label="What activities are you interested ?" description="Check all that apply" inline="true" name="activity-preferences" other="true"> <option label="Adventure activities (horseback riding, ATV, zip line, etc)" value="adventure-activities-horseback-riding-atv-zip-line-etc">Adventure activities (horseback riding, ATV, zip line, etc)</option> <option label="Water Activities (scuba , snorkel, parasailing, water ski)" value="water-activities-scuba-snorkel-parasailing-water-ski">Water Activities (scuba , snorkel, parasailing, water ski)</option> <option label="Arts and theater" value="art-theater">Arts and theater</option> <option label="Casino / Gambling" value="casino-gambling">Casino / Gambling</option> <option label="Golf Course" value="golf-course">Golf Course</option> <option label="Nightlife " value="nightlife-">Nightlife </option> </field> <field type="text" required="true" label="Rental Vehicle Needed? (Ex: Car, Passenger Van, Bus)" description="type N/A if Rental is not needed" name="rental-vehicle-needed-ex-car-passenger-van-bus" subtype="text" className="form-control"/> <field type="text" required="true" label="Do any travelers have accessibility or special needs requirements?" description="ex: wheelchair oxygen food allergies medical conditions" name="do-any-travelers-have-accessibility-or-special-needs-requirements" subtype="text" className="form-control"/> <field type="text" label="Anything you absolutely must do or see on this vacation that is not listed?&nbsp;" name="must-dos" subtype="text" className="form-control"/> <field type="header" subtype="h1" label="Flight Information"/> <field type="radio-group" required="true" label="Do you need flights?" name="do-you-need-flights"> <option label="Yes " value="yes-">Yes </option> <option label="No" value="no">No</option> </field> <field type="text" label="Preferred Departure Airport&nbsp;(Ex: DFW, ATL, MIA)" description="type N/A if flight is not needed" name="preferred-departure-airport-ex-dfw-atl-mia" subtype="text" className="form-control"/> <field type="radio-group" label="Preferred TravelTime" description="(if traveling on a custom itinerary please be mindful of the travel time to and from the destination)" name="preferred-return-time"> <option label="Early Morning" value="early-morning">Early Morning</option> <option label="Afternoon" value="afternoon">Afternoon</option> <option label="Evening" value="evening">Evening</option> <option label="Time with best best price" value="time-with-best-best-price">Time with best best price</option> </field> <field type="radio-group" label="Please provide your preferred departure airport?" name="preferred-departure-time" other="true"> <option label="Spirit Airlines" value="spirit-airlines">Spirit Airlines</option> <option label="Delta Airlines" value="delta-airlines">Delta Airlines</option> <option label="American Airlines Airlines" value="american-airlines-airlines">American Airlines Airlines</option> <option label="Frontier Airlines" value="frontier-airlines">Frontier Airlines</option> <option label="Southwest Airlines" value="southwest-airlines">Southwest Airlines</option> <option label="Airline with best best price" value="airline-with-best-best-price">Airline with best best price</option> </field> <field type="radio-group" label="Please provide your preferred flight class?" name="please-provide-your-preferred-flight-class"> <option label="Basic Economy" value="basic-economy">Basic Economy</option> <option label="Main Cabin" value="main-cabin">Main Cabin</option> <option label="Business Class" value="business-class">Business Class</option> <option label="First Class" value="first-class">First Class</option> </field> <field type="radio-group" label="Seat Choice" description="Subject to Availability" name="seat-choice"> <option label="Aisle" value="aisle">Aisle</option> <option label="Window" value="window">Window</option> <option label="Middle" value="middle">Middle</option> <option label="Any available" value="any-available">Any available</option> </field> <field type="header" subtype="h1" label="Budget and Payment"/> <field type="radio-group" required="true" label="What is your budget amount PER TRAVELER?" description="This gives me a general starting point and can always be changed later." name="budget" other="true"> <option label="$800 to $1,500" value="800-to-1500">$800 to $1,500</option> <option label="$1,500 to $2,500" value="1500-2500">$1,500 to $2,500</option> <option label="$2,500 to $4,500" value="2500-4500">$2,500 to $4,500</option> <option label="$4,500 +" value="4500-">$4,500 +</option> </field> <field type="radio-group" required="true" label="Would you like your quote to include travel insurance?&nbsp;" description="protects your trip costs from any unforeseen cancellations" name="would-you-like-your-quote-to-include-travel-insurance-"> <option label="I ACCEPT Travel Insurance" value="i-accept-travel-insurance">I ACCEPT Travel Insurance</option> <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> </field> <field type="radio-group" required="true" label="Will you need a payment plan? (not available for travel dates less than 45 days)" name="will-you-need-a-payment"> <option label="Yes" value="yes">Yes</option> <option label="No" value="no">No</option> </field> <field type="text" label="Is there anything else that I can do to make this a wonderful experience ? ( i.e. describe the special occasion, requests)" description="What else would you like me to know about your travelers budget and/or travel preferences?" name="is-there-anything-else-that-i-can-do-to-make-this-a-wonderful-experience-ie-describe-the-special-occasion-requests" subtype="text" className="form-control"/> <field type="radio-group" required="true" label="How did you hear about Breakaway Travel?" name="how-did-you-here-about-us" other="true"> <option label="Social Media" value="social-media">Social Media</option> <option label="Referral" value="referral">Referral</option> <option label="Previous Traveler" value="previous-traveler">Previous Traveler</option> </field> <field type="header" subtype="h1" label="PLEASE READ BEFORE SUBMITTING"/> <field type="paragraph" subtype="p" label="Before we get your dream trip rolling✨Quotes arrive within 3–7 days after your form is submitted, and you’ll have 72 hours to review and lock it in. Need to switch things up after confirming? No worries—changes come with a $20 research fee."/> <field type="paragraph" subtype="p" label="Groups of 10 or more require a non-refundable research fee, based on the number of guests (details available upon request)."/> <field type="paragraph" subtype="p" label="I’ll reach out if I need anything extra, and from booking to returning home, We’ve got you covered every step of the way."/> </fields> </form-template> </body> </html>
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