Share your information with Carmen Richardson

Carmen Richardson

Breakaway Travel

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h2" label="Breakaway Cruise Request Form"/>&#13;
		<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. 🌍✈️"/>&#13;
		<field type="text" required="true" label="First name" name="first-name" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Middle name or Middle Initial" 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="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="Preferred method of contact?" inline="true" name="preferred-method-of-contact">&#13;
			<option label="Phone" value="phone">Phone</option>&#13;
			<option label="Email" value="email">Email</option>&#13;
			<option label="Text" value="text">Text</option>&#13;
		</field>&#13;
		<field type="select" required="true" label="Cruise Line (choose option)" name="cruise-line-choose-option" className="form-control">&#13;
			<option label="Carnival" value="carnival">Carnival</option>&#13;
			<option label="Royal Caribbean International" value="royal-caribbean-international">Royal Caribbean International</option>&#13;
			<option label="Virgin Voyages (Adult Only)" value="virgin-voyages-adult-only">Virgin Voyages (Adult Only)</option>&#13;
			<option label="Disney  Cruise" value="disney-cruise">Disney  Cruise</option>&#13;
			<option label="Margaritaville Cruise   " value="margaritaville-cruise-">Margaritaville Cruise   </option>&#13;
			<option label="Norwegian Cruise" value="norwegian-cruise">Norwegian Cruise</option>&#13;
			<option label="Celebrity Cruises" value="celebrity-cruises">Celebrity Cruises</option>&#13;
			<option label="Prince Cruises" value="prince-cruises">Prince Cruises</option>&#13;
			<option label="River Cruise" value="river-cruise">River Cruise</option>&#13;
			<option label="Other" value="other">Other</option>&#13;
		</field>&#13;
		<field type="select" required="true" label="What is the Special Occasion? (choose option)" name="what-is-the-special-occasion" className="form-control">&#13;
			<option label=" Celebration (Birthday, Graduation etc..)" value="-celebration-birthday-graduation-etc"> Celebration (Birthday, Graduation etc..)</option>&#13;
			<option label="Family Cruise" value="family-cruise">Family Cruise</option>&#13;
			<option label="Solo Cruise" value="solo-cruise">Solo Cruise</option>&#13;
			<option label="Anniversary /Honeymoon Cruise" value="anniversary-honeymoon-cruise">Anniversary /Honeymoon Cruise</option>&#13;
			<option label="Other" value="other">Other</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="Is this for a group? (8 or more cabins)" description="Eight are more cabins are subject to a research fee" inline="true" name="is-this-for-a-group-8-or-more">&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
			<option label="No" value="no">No</option>&#13;
		</field>&#13;
		<field type="text" required="true" label="Number of adults attending? (Age 18+)" description="Children age 13+ are priced as adults" placeholder="If for a group 10 or more  only put # of adults" name="text-1768440560076" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Number of children attending &amp;amp; age at time of travel. (Under age 17)" description="Please provide ages at time of travel" placeholder="If for a group 10 or more  only put # of children" name="number-of-children-attending" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="Number of Cabins needed" inline="true" name="hotel-preference" other="true">&#13;
			<option label="1" value="1">1</option>&#13;
			<option label="2" value="2">2</option>&#13;
			<option label="3" value="3">3</option>&#13;
			<option label="4" value="4">4</option>&#13;
			<option label="Group Cabins (8+)" value="group-cabins-8">Group Cabins (8+)</option>&#13;
		</field>&#13;
		<field type="checkbox-group" required="true" label="Travel Protection Insurance" inline="true" name="vibe-preference">&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
			<option label="No" value="no">No</option>&#13;
		</field>&#13;
		<field type="header" subtype="h2" label="Travel Preferences"/>&#13;
		<field type="text" required="true" label="Departure City&amp;nbsp;" placeholder="i.e. Gavelston , Miami , New Orleans etc..." name="departure-port-" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Destination" placeholder="i.e. The Caribbean , Mexico, Alaska, etc…" name="destination" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Proposed Cruise Date (Enter in month and year if specific date is unknown)" description="multiple options can be submitted" name="proposed-cruise-date-enter-in-month-and-year-if-specific-date-is-unknown" subtype="text" className="form-control"/>&#13;
		<field type="select" required="true" label="How many cruise days?" name="select-1677516565978" className="form-control">&#13;
			<option label="2-5 days" value="25-days">2-5 days</option>&#13;
			<option label="6-9 days" value="69-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="Stateroom Specifics" inline="true" name="seat-preference">&#13;
			<option label="Interior Cabin" value="interior-cabin">Interior Cabin</option>&#13;
			<option label="Window Cabin" value="window-cabin">Window Cabin</option>&#13;
			<option label="Balcony Cabin" value="balcony-cabin">Balcony Cabin</option>&#13;
			<option label="Suite Cabin" value="suite-cabin">Suite Cabin</option>&#13;
			<option label="Various (Group Cruises)" value="various-group-cruises">Various (Group Cruises)</option>&#13;
		</field>&#13;
		<field type="header" subtype="h2" label="Location"/>&#13;
		<field type="select" label="&amp;nbsp;Deck Preference&amp;nbsp;" name="-deck-preference-" className="form-control field-hidden">&#13;
			<option label="Upper Deck" value="upper-deck">Upper Deck</option>&#13;
			<option label="Mid Deck" value="mid-deck">Mid Deck</option>&#13;
			<option label="Lower Deck" value="lower-deck">Lower Deck</option>&#13;
			<option label="Various (Group option)" value="various-group-option">Various (Group option)</option>&#13;
		</field>&#13;
		<field type="radio-group" label="&amp;nbsp;Ship&amp;nbsp; Room Selections&amp;nbsp;" inline="true" name="bed-preference">&#13;
			<option label="Front " value="front-">Front </option>&#13;
			<option label="Middle" value="middle">Middle</option>&#13;
			<option label="Back" value="back">Back</option>&#13;
			<option label="Various (Group cruise)" value="various-group-cruise">Various (Group cruise)</option>&#13;
		</field>&#13;
		<field type="select" required="true" label="Dining Preference&amp;nbsp;" name="dining-preference-" className="form-control">&#13;
			<option label="Early (6pm)" value="early-6pm">Early (6pm)</option>&#13;
			<option label="Late (7:30pm)" value="late-730pm">Late (7:30pm)</option>&#13;
			<option label="Anytime Dining " value="anytime-dining-">Anytime Dining </option>&#13;
		</field>&#13;
		<field type="select" required="true" label="Dining Preference&amp;nbsp;" name="select-1768441065955" className="form-control">&#13;
			<option label="Early (6pm)" value="early-6pm">Early (6pm)</option>&#13;
			<option label="Late (8pm)" value="late-8pm">Late (8pm)</option>&#13;
			<option label="Anytime Dining " value="anytime-dining-">Anytime Dining </option>&#13;
		</field>&#13;
		<field type="textarea" label="Please add any Loyalty Numbers&amp;nbsp;" description="Will help identify promotions" placeholder="VIPF number   Royalty program number" name="please-add-any-loyalty-numbers-here-along-with-name-" className="form-control"/>&#13;
		<field type="text" label="Any other info you would like me to know or additional requests?" placeholder="Special Accommodations  Diet restrictions  etc.." name="any-other-info-you-would-like-me-to-know-or-additional-requests" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="How did you hear about Breakaway Travel?" name="how-did-you-hear-about-breakaway-travel">&#13;
			<option label="Social Media" value="social-media">Social Media</option>&#13;
			<option label="Referral" value="referral">Referral</option>&#13;
			<option label="Previous traveler" value="previous-traveler">Previous traveler</option>&#13;
			<option label="Other" value="other">Other</option>&#13;
		</field>&#13;
		<field type="header" subtype="h1" label="PLEASE READ BEFORE SUBMITTING"/>&#13;
		<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 fee. 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."/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>