Share your information with Rebecca Fleishman

Rebecca Fleishman

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		<field type="header" subtype="h2" label="You&#39;re going on Vacation!"/>&#13;
		<field type="text" label="Prefix" name="prefix" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Legal First name" name="first-name" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Middle name (if listed on passport/ License)" 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" 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="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="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" label="City" name="address-city" subtype="text" className="form-control"/>&#13;
		<field type="text" label="State" name="address-state" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Zip" name="address-zip" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Country" name="address-country" subtype="text" className="form-control"/>&#13;
		<field type="checkbox-group" label="Number of Adults" inline="true" name="number-of-adults">&#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="5" value="5">5</option>&#13;
		</field>&#13;
		<field type="checkbox-group" label="Number of Children" inline="true" name="number-of-children">&#13;
			<option label="0" value="0">0</option>&#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="5" value="5">5</option>&#13;
			<option label="6" value="6">6</option>&#13;
			<option label="7" value="7">7</option>&#13;
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		<field type="text" label="Please list ages of children below" name="please-list-ages-of-children-below" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" label="What is your budget for entire trip? ie. Cruise/ airfare/ excursions" description="This is just an estimate and having this info gives us a good starting point." name="what-is-your-budget-for-entire-trip-ie-cruise-airfare-excursions" other="true">&#13;
			<option label="$2,500 or less" value="2500-or-less">$2,500 or less</option>&#13;
			<option label="$5,000 or less" value="5000-or-less">$5,000 or less</option>&#13;
			<option label="$7,500 or less" value="7500-or-less">$7,500 or less</option>&#13;
			<option label="$10,000 or less" value="10000-or-less">$10,000 or less</option>&#13;
			<option label="$15,000 or less" value="15000-or-less">$15,000 or less</option>&#13;
			<option label="$20,000-$30,000" value="2000030000">$20,000-$30,000</option>&#13;
			<option label="more than $30,000" value="more-than-30000">more than $30,000</option>&#13;
		</field>&#13;
		<field type="radio-group" label="There could be special discounts for certain groups. Do any of these apply to you or someone in your travel party?&amp;nbsp;" name="there-could-be-special-discounts-for-certain-groups-do-any-of-these-apply-to-you-or-someone-in-your-travel-party-" other="true">&#13;
			<option label="Over 55" value="over-55">Over 55</option>&#13;
			<option label="Active or retired Military" value="active-or-retired-military">Active or retired Military</option>&#13;
			<option label="Fire Dept or EMT" value="fire-dept-or-emt">Fire Dept or EMT</option>&#13;
			<option label="Florida Resident " value="florida-resident-">Florida Resident </option>&#13;
		</field>&#13;
		<field type="textarea" label="Which Sailing/s and/or Cruise lines are you most interested in? If not interested in a cruise, where would you like to go? Be as detailed as possible." name="which-sailings-andor-cruise-lines-are-you-most-interested-in-if-not-interested-in-a-cruise-where-would-you-like-to-go" className="form-control"/>&#13;
		<field type="text" label="Any additional information you wish to provide?" name="any-additional-information-you-wish-to-provide" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="Dream Destinations by Becca LLC Client Agreement"/>&#13;
		<field type="paragraph" subtype="p" label="When you retain Dream Destinations by Becca LLC to help plan your travel, you&#39;re hiring a professional travel advisor to ensure that your trip is tailored to your taste, preferences, and budget. You get the benefit of my skill, experience and training, my professional relationships, and my industry connections. My Professional Services Fee covers your consultation, our research and recommendations, preparation of quotes and itineraries, reserving and booking each element of your trip, securing quotes for comprehensive travel insurance, administration of your booking from deposit to departure, and follow-up post-trip with suppliers (as needed)."/>&#13;
		<field type="paragraph" subtype="p" label="By checking the box below and submitting this form, you acknowledge that you are hiring me to plan your trip and that you have read and agree to my Terms and Conditions of booking, which are located at:&amp;nbsp; www.terms-conditions.net&amp;nbsp;"/>&#13;
		<field type="checkbox-group" required="true" label="Client Agreement" name="client-agreement">&#13;
			<option label="I agree" value="i-agree">I agree</option>&#13;
		</field>&#13;
		<field type="header" subtype="h1" label="Travel Insurance Acknowledgement"/>&#13;
		<field type="paragraph" subtype="p" label="Emergencies can happen when you least expect them. Dream Destinations by Becca LLC highly recommends that all clients purchase a travel insurance policy to protect their investment in their travel. Cruise lines, airlines, hotels, and tour operators all charge high penalties for cancellation, ranging from the full deposit to no refund at all. And, keep in mind that most health insurance policies will not cover you when you are out of the country. Travel insurance can protect you in the event of Trip Cancellation, Trip Delay, Trip Interruption, Missed Connection, Baggage Loss, Theft or Damage, Baggage Delay, Emergency Medical and Dental Expenses, and Emergency Medical Transportation, among other unforeseen circumstances."/>&#13;
		<field type="paragraph" subtype="p" label="Please also note that in order for you to obtain coverage for certain pre-existing conditions, or for supplier default, your policy must be purchased at the time of booking or shortly thereafter (depending on the terms of the policy)."/>&#13;
		<field type="paragraph" subtype="p" label="Please understand that I am not a registered insurance agent, and cannot legally provide specific advice or information regarding insurance. I will gladly secure a quote for you, upon request, and if Dream Destinations by Becca LLC does not, or is not legally able to secure coverage on your behalf, it is my strong recommendation that you purchase a policy on your own."/>&#13;
		<field type="paragraph" subtype="p" label="I acknowledge that Dream Destinations by Becca LLC has recommended or offered travel insurance protection to me. Should I choose not to purchase such a policy, I accept all responsibility for declining to secure coverage."/>&#13;
		<field type="checkbox-group" required="true" label="Travel Insurance Acknowledgement" name="checkbox-group-1758966702586">&#13;
			<option label="I agree" value="i-agree">I agree</option>&#13;
		</field>&#13;
	</fields>&#13;
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  </body>
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