Registration Form
(Please print this form and send or fax it to the address at bottom)
2011 Living History Re-enactor's Conference
Registration Form
|
Participant Name |
Age |
| . |
. |
| . |
. |
| . |
. |
| . |
. |
| . |
. |
| . |
. |
| . |
. |
| . |
. |
Street Address:__________________________________________________
City: _____________________ State: ______ Zip: ___________________
Email (please print VERY clearly): ____________________________________
Phone(s): ________________________________________________________
Days of Participation (please circle all that apply): Fri., April 30. . . . . . Sat. May 1
March 17 Workshops attending (1 - 5 pm):
Participant Name |
Workshop |
Extra Fee |
| |
|
|
| |
|
|
| |
|
|
| |
|
|
| |
|
|
| |
|
|
| TOTAL: |
----- |
$________ |
March 18 Sign Ups for Limited Seating Workshops:
Participant Name |
Workshop |
| |
|
| |
|
| |
|
| |
|
| |
|
Special Accomodation Needs:
Will you be staying at the This Is The Place Heritage Park ("camping" in one of their buildings?): Y or N
Other Special Accomodations (wheelchair, etc.):
Pricing (these are 2010 prices; 2011 prices are subject to change)
Early Registration (Received by _________________)
Late Registration (Received after __________________):
Saturday-only registration (Received by _________________)
Late registration for Saturday-only (Received after _________________)
____ Included is my check for $___________________________
____ Please charge my credit card $ _________________________________________
Credit Card Number: ____________________________________ Exp. Date: ___ / ___
Authorized Signature: __________________________________
Mail to:
This Is The Place Heritage Park
2601 East Sunnyside Avenue
Salt Lake City, Utah 84108
(801)-582-1847
Or email the information on this form to:
"Holly Curtis" <hcurtis at thisistheplace dot org>
Photo Release
I hereby grant the Rocky Mountain Living History Consortium and its authorized participating photographers permission to use my or my child or children’s (or the children over whom I have guardianship) likeness in a photograph in any and all of its publications, including website entries, without payment or any other consideration.
I understand and agree that these materials will become the property of the Rocky Mountain Living History Consortium and its authorized participating photographers and will not be returned.
I hereby irrevocably authorize the Rocky Mountain Living History Consortium and its authorized participating photographers to edit, alter, copy, exhibit, publish or distribute this photo or these photos for purposes of publicizing the Rocky Mountain Living History Consortium's programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph(s).
I hereby hold harmless and release and forever discharge the Rocky Mountain Living History Consortium and its authorized participating photographers from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
I am 21 years of age and am competent to contract in my own name and/or for the name(s) of my child or children (or the children over whom I have guardianship). I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.
Photo Subject(s) (please print):
Contact Information: |
Phone: |
Email (please print VERY clearly):
|
Address:
|
Signature: Date:
| 
