SANTO DOMINGO HASH HOUSE HARRIERS

REGISTRATION FORM (ONE PER PERSON)

AGPU 2017

30 YEARS ANNIVERSARY

Hotel Villa Serena, Las Galeras, Samana, DOMINICAN REPUBLIC

Friday, November 04th to Sunday, to 05th, 2017

Write in legible block letters.

First Name / Surname / HASH Name None

Telephone Number / E-MailAddress
Fax / Male Female
Nationality / Passport # / Date of Birth (day,month,year)
Name of your HASH / Location of yourHASH (city, country)
T-Shirt Size

Small Medium Large X-Large XXL XXXL

Registration Fees:

All Registration fees must be delivered to Dulce (Sweet Lips)Guzman by no later thanMonday 31st July. All payments after that date will incur a 10% extra charge. No room will be guaranteed if full payment has not been made by this date. The hotel cannot guarantee a room or the same price after this date.

USD$275Single

USD$ 195Double

USD$170Triple – 3 persons per room & 2 beds

USD$ 165Quadruple - 4 persons per room2 beds

USD$ 140Child (2 – 12 yrs)

USD$On RequestAdditional nights(please indicate the number of nights:_____).

These rates are for 2-night with food per person plus all Hash activities and goodies included. Bank transfers should be made to the account specified below and please send confirmation of this signed and scanned copy of the registration form to e-mail:

BANK TRANSFER PAYMENT DETAILS

Bank Name: / BANCO POPULAR DOMINICANO
Bank Location: / Av John F Kennedy, #20, Esq. Av Maximo Gomez, Torre Populatr, Santo Domingo, Dominican Republic
Account Number: / 72699306
Beneficiary Account Name: / Michael D. O'Kelly
Type of Account: / Savings $USD
BANK SWIFT CODE: / BPDODOSX
Intermediate Bank:
ABA: / Bank of New York
021000018

SPACE IS LIMITED - FIRST PAIDIN FULL - FIRST SERVED!

THE FINE PRINT (whatever happen to me is my own fault!)

I understand that my consent to these provisions is given in consideration for being permitted to participate in this event. I am aware of, and voluntarily assume the risks of coming to this event. If I am injured, I agree that I will not sue, or otherwise hold responsible, the Santo Domingo Hash House Harriers, the Organizing Committee, or any affiliated individuals, or any run sponsor and/or their employees. In other words, I take responsibility for my own actions and I will not try to screw anybody connected with this event – and maybe, for the first time in my life, I will be responsible for myself and my actions.

I further understand that I am totally responsible for any incidental expenses over and above the event package price that are charged to my room.

Signature______Date______

FILL OUT THIS FORM SIGN SCAN AND SEND TO – ON ON

(Please note that this form is NOT valid without a signature, a date, and full payment of registration fees).

For Official Use Only:

Date Received ______Date Entered ______Reg. No. ______

Remarks: ______