Start Your Registration for Pine Mountain 2008

Information Needed Please
The information requested below will help us make your stay a memorable and enjoyable visit. Thank you for choosing Crop Inn!

Please complete the fields below, then click the Submit button.
(
*Indicates required field.)
   
General Info
*Name of Party:
*Your Name:
Other Names in your Party:

*Mailing Address:
(Street, City, State Zip)

*Email Address:
*Daytime Phone Number:
  *Payment By: Credit Card Check
*Type of Retreat: Self Service
Mid Service
Extended Hours Pkg: Yes No
Self-Service Extended Stay Pkg: Yes No
*2008 Weekend Date Selected:
Dietary Restrictions:
Food Allergies:
How long have you been
scrapbooking?
years
Any classes or techniques
you'd enjoy learning?
(Not applicable to Self-Service Weekends.)
*How did you hear about us?
If "Store" above, Name of Store:
Policies
*Release Agreement:

        I Accept
Medical Info
*Authorization for Treatment:
        I Accept
*Medical Insurance Provider:
  *Member/Policy Number:
*Physician's Name:
*Physician's Phone:
Please List Any Health Concerns:
Please List Any Allergies:
Emergency Contact
*Please List One or More Emergency Contacts: