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

   Registration Form –

Please circle applicable weekend(s) you will attend.

"South of the Border" Mexico

February 24, 25,,26, 2017 - $80.00 when paid by January 4, 2017 **

"Weekend In Paris" France  SOLD OUT

April 21, 22, 23, 2017 - $80.00 when paid by March 1, 2017 **

"Birthday Celebration In The Caribbean" SOLD OUT

July 21, 22, 23, 2017  Birthday Bash $95.00 when paid by June 1, 2017 **

REGISTRATION FOR JULY CLOSES ON JUNE 16, 2016 - so please register earyl.

"Autumn in Italy"

September 22, 23, 24, 2017 - $80.00 when paid by August 1, 2017 **

"Marche' de Noel" - Germany  SOLD OUT

November 17, 18, 19, 2017 - $80.00 when paid by October 1, 2017 **

** after dates listed weekend registration is $90.00 for each escape except for the July Birthday Bash which is $105.00

Name _______________________________________

Email _______________________________________

Phone _______________________________________

Weekend Registration $80.00** _______________

Weekend Registration $90.00 after dates listed above ______________________

BIRTHDAY BASH (JULY) $95.00** _______________________

Birthday Bash Weekend Registration $105.00 after June 1, 2017 _____________________

T-Shirt Size S - XL (July only) _________________

Add $5.00 for t-shirts ______XXL   ___________XXXL (July only)

Total enclosed ________________________________

Please seat me with my friend(s) who are also attending ____________________

___________________________________________________

PLEASE NOTE:  I have read the cancellation policy and understand that there are no refunds unless an event is cancelled. __________(Initials please.)

There is a $35.00 fee for any checks returned by your bank.

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 also give permission for any photos, videos or other media to be posted to websites and other outlets without any compensation.

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

________________________________________

PAYMENT MUST BE MADE IN FULL AT THE TIME OF REGISTRATION, Seats are only held for 7 days from the date of reservation. PLEASE MAKE YOUR CHECK PAYABLE TO Jan DuRall and mail with signed registration form to 1091 Monticello Drive, Aurora, IL 60506

For further information please email Jan at scrapndream@ att.net or call Jan at 630-862-4401.

Please mail completed registration form and payment to:

Jan DuRall

1091 Monticello Drive

Aurora, IL 60506