Registration Form for "Simply A Scrappin Escape"

PLEASE CIRCLE THE DATE/DATES OF THE "ESCAPE" YOU WANT TO ATTEND

Please register me for the following "Simply A Scrappin Escape" dates:

February 17, 18, 19, 2012

April 27, 28, 29, 2012

July 27, 28, 29, 2012

September 28, 29, 30, 2012

November 30, December 1, 2, 2012

Each "Escape" weekend is only $75.00 per person excluding hotel

PLEASE NOTE:  There are NO REFUNDS GIVEN UNLESS AN EVENT IS CANCELLED and THERE IS A $35.00 CHARGE FOR ANY CHECK RETURNED FROM YOUR BANK UNPAID.

Name: ________________________________________

Email: ________________________________________

Phone: ________________________________________

Total weekend fee excluding hotel $75.00 ____________

(Includes "Night Owl Crop", all day Friday, Saturday and Sunday)

Optional Friday lunch of pizza and salad only $5.00 _______

Pizza choice:

Cheese __________

Cheese and Sausage __________

Cheese and Pepperoni ___________

Veggie __________________

 Amount Enclosed: ______________________________

Check number __________________________________

I am attending with friends including _________________

________________________________________________

I will attend the "Night Owl Crop" starting at 12:01 AM _______

Please seat us together since seating is assigned.

RELEASE AND HOLD HARMLESS AGREEMENT

I, ________________________________________________, have the opportunity to participate in a “Simply A Scrappin Escape” retreat beginning on _______________20___ and ending on ____________________20__________ at the Hampton Inn, 2423 Bushwood Drive, Aurora, IL60506.

I, the undersigned, am aware of the possibility of injuries or accidents while on this retreat.

In consideration being allowed to participate in the scrapbook retreat, I agree to assume full responsibility for my safety and medical treatment while participating in the retreat. I agree to release, indemnify, and hold harmless Janice E. DuRall/Scrap 'N Dream/Simply A Scrappin Escape, and all members of her family from any and all liability for personal injury including death or for damage to property that may occur to me or to others as a result of my participation in the scrapbook retreat. The terms hereof shall also serve as a release, forever discharge, indemnify and hold harmless Janice DuRall, Scrap ‘N Dream and Simply A Scrappin Escape from any and all claims, demands or causes of action of any type or nature, which are in any way connected with my participation and an assumption of risk for my heirs, executor, and administrator and for all members of my family and may be pleaded as a bar to litigation.

Jurisdiction of this matter and venue shall lie in Aurora, Kane County, Illinois.

I have read the Release and Hold Harmless Agreement and understand and voluntarily accept its terms.

________________________________________

Please mail completed registration form and payment to:

Jan DuRall

1091 Monticello Drive

Aurora, IL 60506