Required Form - Please Print and Fax

Registration Release Policies and Authorization

• Every guest of Crop Inn is required to complete and return this form to Crop Inn prior to their arrival.
• Please print and complete this form. Initial and sign in the appropriate spaces.
• Please fax or mail this form to confirm your registration and if submitting check please make payable to Crop Inn.

Date of Arrival:         Phone Number:

Your Name:

Your Address:

Name of Party:

Name(s) of All Guest(s):

Type of Retreat (circle one): Self-Service  Mid-Service Full-Service

Registration amount for weekend:$_________

Additional Hours Option: $15 (Sef-service and Mid-Service weekends Only) Please Check One ________Yes or _________No

Additional Stay Option: $50 (Self-service and MId-Service weekends Only) Please Check One _______Yes or ________No

Total Amount Enclosed: $____________(US Dollars Only)

Your Address: Email (required)

Dietary Restrictions:

Food Allergies:

How long have you been scrapbooking? years

Any Classes You’d Enjoy Learning?(Not applicable to Self-Service Weekends.)

How did you learn about us? (Circle one):    Store    Advertisement    Craft Fair    Friend    Other

If you selected Store, which one?

Part I - Policies

The die cutting, eyelet setting, punch and scrapbook equipment provided at Crop Inn is for personal use while working at Crop Inn. If you are unfamiliar with the equipment please see instructions or ask. Please do not cut more than 2 pieces of paper at a time as this may cause damage to the tray, roller, foam or die blades. The foam side of the die must be facing up. Use die cuts, punches and equipment at your own risk.

I understand that the scrapbook equipment ( including die cutting machine, dies, punches, eyelet setting equipment, and other equipment at Crop Inn), may cause injury if not used carefully and correctly. I release and agree to hold harmless, Crop Inn, for any injuries sustained to myself as a result of my use of the equipment which has been provided for my use. My signature indicates that I have read and understand the policies of Crop Inn and acknowledge the fact that I am solely liable for damage to equipment caused by improper use.

(initial)

Crop Inn, its officers and employees will be held harmless against all loss, expenses, damages and liabilities in the event of injury or accident caused by or to retreat registrant or her property. We advise you to leave your valuables at home.

(initial)

Crop Inn, reserves the right to expel anyone from the premises for inappropriate behavior or the intent to do harm to others. Anyone requested to leave will not receive a refund of any portion of their retreat fees.

(initial)

I consent to the use of photos or video in which I may appear, or quotes I make regarding Crop Inn to be used in the marketing and publicity of Crop Inn.

(initial)

I have read and understand the policies outlined above for Crop Inn.

Your Name

Your Signature Date

Part II - Authorization for Treatment

In the event of an emergency, I hereby give permission to the medical personnel selected by Crop Inn, to order x-rays, routine tests, administer emergency treatment and to release any records necessary for medical or insurance purposes and to provide or arrange as necessary related transportation for me in the event an emergency contact is unable to be reached and I am unable to do so myself. I hereby give permission to Crop Inn personnel to secure and administer treatment, including hospitalization for me in the event I an unable to do so myself. This authorization shall remain in effect through (the last day of retreat).

Your Name

Your Signature Date

Each retreat registrant is required to provide their own medical insurance.

Health Insurance Provider

Member/Policy #

Doctor/Physician’s Name Phone #

Do you have any serious health problems we should know about? (yes/no)

Please List All Health Concerns

Are you allergic to anything? (yes/no)

Please List All Allergies

Please bring allergy medication with you if necessary.

In case of an emergency who should we contact?

Name/Relation

Phone #

Secondary Name/Relation

Phone #