Chrysalis Moon Festival 2017 –Registration Form

July 19th, 2017 – July 23rd, 2017

PLEASE NOTE:All payments must be post-marked by dates listed to receive price stated.

Lodging/bed with amenities:First come, first served. * Note: medicalelectricity priority (see page 2).
Legal name: / Phone:
Address: / Secondary phone (optional):
City: / State: / Zip:
Email: / Pagan name (optional):

Full Festival Registration

Lodge/Bed Subject to availability / Lodge/Bed with amenities
Until July 10 / Tent or pop-up Trailer camping
Until July 10 / One registration form per adult and/or Minor
Adults (18+) / $135.00 / $95.00 / Circle your selection
Minor: 0 to 11 / 45.00 / Free!
Minor: 12 to 14 / $65.00 / $40.00
Minor: 15 to17 / $85.00 / $55.00
Minors 0 to 17 must be accompanied by legal parent or guardian only!
College Students (age 18+ with college ID)
$125.00 $85.00
TOTAL amountfor registration
Week End Registration (Fri., Sat., Sun.)
July 21 – 23
All Week End options must be Pre-festival Registrations / Saturday with overnight
July 22-23 / Saturday only
Day Pass
July 22
Until July 10 / Until July 10 / Until July 10
Registration for / Lodge/ Bed
Subject to availability / Camp
Tent or pop-up / Camp
Tent or pop-up
Adult 18+ / $120.00 / $80.00 / $55.00 / $40.00
Minor: 0 - 11 / $40.00 / $0 / $0 / Free
Minor:12 -14 / $45.00 / $35.00 / $35.00 / $30.00
Minor:15 -17 / $70.00 / $50.00 / $45.00 / $35.00
College student with current ID
$110.00 / $75.00 / $45.00 / $35.00

This is a Lodge with assigned bed, tent, and pop-up trailer camping event. Each Lodge registrant will be assigned a bed in a lodge. There are several lodges with multiple bedrooms of different capacities.

Lodges have electricity, flush toilets, showers, and full communal kitchen. Sharingof room space is required.

Please list here the names of others you wish to share a Lodge/bedroom with:

______

Festival Dates: Wednesday, July 19th, 2017 through Sunday, July 23rd, 2017

Gates open at 10:00am ET, Wednesday July 19th, close July 23rdat 3:30 pm

Festival location:

Ronora Lodge and Retreat Center inlower So. Western Michigan, off of interstate 94

9325 Dwight Boyer Rd
Watervliet, MI 49098

Phone: 269 463-6315

This is a Lodge/bed with amenities, tentand pop-up trailer camping event. Please note: Electricity is extremelylimited in the tent/pop-up camping area.

* Electricity* Priority: islimited to only persons withmedical conditions such as C-Pap’s, etc. at no extra charge. There are no exceptions.Must present doctor’s orders.

Note: Each adult must sign then submit a waiver and photo release with theirsnail mail registration form.

PAYMENT: Make check or money order to: Chrysalis Moon, Inc.

Payment through PayPal at:

Mail all forms and check/money order payments to:

Joe Gladkowski

1310 Clement St.

Joliet, IL 60435

Hold my spot! For tent and pop-up campers only, we are offering the option of putting a down payment on your festival participation. Just check the box and send $30.00 per person with complete registration form, signed waivers for each person, and we will save you a space. Festival prices will remain fixed from the date registration is received.Balanceof registration is due by July 10, 2017 or both fee and space will be forfeit with no exceptions. The $30.00 is nonrefundable.

CM Festival Cancellation/Refund Policy:

Written/email cancellation requests received by July10, 2017 will be refunded in late August minus half of the registration fee for processing. If request is made after July 10th there will be no refund granted.

Payment PlanOption for Chrysalis Moon Festival 2017

To help ease the burden of coming up with the full amount of registration fees all at once, we have a payment plan option. If you choose this option, all rules must be adhered to with no objections.

The payment option rules:

The full amount of all registration fees will be divided into 3 (three) or 4 (four) equal parts.

First payment must be made when you choose this option. Each payment is to be made monthly.

The first payment must be accompanied with all registration and signed waiver forms.

No matter what month you choose to start the 3 month payment plan, the last payment is due (postmarked) no later than the third month.

Pay Palis an option for this payment plan at

Note: Your e-mail address must be clearly legible on the registration form. You will be reminded each month by e-mail prior to the payment due date.

Last date to take advantage of the payment plan option is March 01, 2017.

If final payment is not postmarked prior to last date of the third or fourth consecutive month all registration fees will be forfeit with no refund, no exceptions.

Check or money order made to: Chrysalis Moon, Inc.

Contact Joe for info.

WAIVER CM2017

Do not sign below until you have read, understood and agreed to the guidelines and procedures for Chrysalis Moon Festival 2017.

  • I/we have read the entire contents of the registration form. I/we agree to comply fully with Chrysalis Moon, Inc.and RonoraLodge and Retreat Center (hereafter referred to as Ronora) guidelines. (See Chrysalis Moon web site).
  • I/we agree to sign up for and perform at least 2 hours of serviceper adult during the festival.
  • I/we will not bring anyone who is not pre-registered or identified on this form.
  • All minors under my/our care are identified by name on this form.
  • I/we assume full responsibility for my/our personal welfare, personal property and any minors in my/our care at Chrysalis Moon Festival under all circumstances.
  • I/we understand that I/we need to exercise caution to maintain the health and safety of myself/ourselves and others.
  • I/We assume full responsibility for my/our conduct related to the festival site environment including land protection and conservation.
  • I/We understand that any medical, childcare, and other services at the festival I/we choose to use for myself/ourselves and/or minors in my/our care are totally at my/our own risk.
  • I/We understand that if I/we and/or the minors in my/our care choose not to comply with Chrysalis Moon, Inc. or Ronora’s guidelines, I/we will be required to leave without refund and I/we agree to comply.
  • I/we agree to leave pets/animal familiars at home. Service animals are allowed with the submittal of proof of doctor certification prior to the festival.
  • I/we agree to remove all trash created by myself/ourselves from the festival site.
  • I/WE UNDERSTAND THAT ANY INAPPROPRIATE OR ABUSIVE BEHAVIOR WILL RESULT IN MY/OUR IMMEDIATE REMOVAL FROM THE FESTIVAL WITHOUT REFUND.

I/We will have the following minors in my/our care (list all legal names and ages here)

______

______

(Add additional page, if necessary.)

I agree to hold harmless Chrysalis Moon, Inc., its directors, staff, volunteers and associates; and Ronora Lodge and Retreat Center, its owners, staff, volunteers and/or associates—for any personal injury or loss occurring to me/us or any minors under my/our care as a result of my/our participation in any activity connected with Chrysalis Moon, Inc. under any circumstances. I/We agree to abide by the privacy and photo guidelines of Chrysalis MoonFestival and Ronora as outlined on this waiver and registration form.

My/Our signature below indicates that I/we understand and are in full agreement with the terms of this waiver.

Signature: ______Date: ______

CHRYSALIS MOON 2017 PHOTO RELEASE FORM

(Required - one form per adult registrant)

I ______hereby authorize and give permission to Chrysalis Moon, Inc. and/or Ronora staff to use photographs of me and mine in the promotion of the festival and for personal use by attendees. I acknowledge that these photographs could be used in such materials as flyers, brochures, newsletters, annual reports, visual presentations (power points) and on CM websites for the Chrysalis Moon festival. I also understand that these photos may be shared with other event organizers in the promotion of Chrysalis Moon festival.

______

(Signature) (date)

1 01/02/2017 JG