Share your information with Merry Jennifer Markham

Merry Jennifer Markham

MMarkham Travel

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		<field type="header" subtype="h1" label="April 9–12, 2026 | Miraval Arizona 🌿&amp;nbsp;"/>&#13;
		<field type="paragraph" subtype="p" label="We’re so glad you’re joining us!"/>&#13;
		<field type="paragraph" subtype="p" label="This registration form is the first step to officially reserve your place at the RestoreRx Arizona retreat for women physicians. Once completed, you’ll receive an invoice for the retreat fee. This fee covers our private group experiences—including three curated group dinners and special wellness activities designed to foster rest, reflection, and reconnection."/>&#13;
		<field type="paragraph" subtype="p" label="Please note:"/>&#13;
		<field type="paragraph" subtype="p" label="👉 Your spot is not confirmed until the retreat fee is received."/>&#13;
		<field type="paragraph" subtype="p" label="👉 Once payment is complete, you’ll receive the private booking link to reserve your room at our exclusive group rate at Miraval Arizona."/>&#13;
		<field type="header" subtype="h2" label="Attendee Information&amp;nbsp;"/>&#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="text" label="Preferred name" name="preferred-name" subtype="text" className="form-control"/>&#13;
		<field type="date" required="true" label="Date of Birth" name="date-of-birth" 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="text" label="Country" name="address-country" 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="text" required="true" label="Email Address" name="email" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="What is your specialty/field of practice?" name="do-any-travelers-have-allergies-that-we-should-be-aware-of" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Do you have any special requests that we may share with Miraval Arizona once you&#39;re booked?" name="text-1745532389670" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="You may bring a guest/plus-one who is not a retreat attendee. The fee is discounted for your guest ($415) so that they may join us for the private group dinners. Do you plan to bring a guest who is not a regular retreat attendee?" name="text-1745531864469" subtype="text" className="form-control"/>&#13;
		<field type="text" label="If you are bringing a guest/plus-one who is not a retreat attendee, please share their name here:" name="text-1746890909833" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Is there anything else you&#39;d like us to know?" name="text-1745692638239" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="💌 Do you wish to be added to the MMarkham Travel newsletter?" name="do-you-wish-to-be-added-to-our-newsletter">&#13;
			<option label="Yes, please" value="yes-please">Yes, please</option>&#13;
			<option label="No, thank you" value="no-thank-you">No, thank you</option>&#13;
		</field>&#13;
		<field type="paragraph" subtype="p" label="🌿&amp;nbsp; Almost done! 🌿&amp;nbsp;"/>&#13;
		<field type="paragraph" subtype="p" label="Be sure to hit Submit below to complete your registration.&amp;nbsp;"/>&#13;
		<field type="paragraph" subtype="p" label="Once we receive your form, you&#39;ll be emailed an invoice for the $740 retreat fee (and guest fee, if applicable)."/>&#13;
		<field type="paragraph" subtype="p" label="&amp;nbsp;After payment is received, you&#39;ll get access to the booking link for Miraval Arizona so that you may reserve your room at our exclusive group rate."/>&#13;
		<field type="paragraph" subtype="p" label="Can&#39;t wait to see you there!"/>&#13;
	</fields>&#13;
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