Adirondack Astronomy Retreat

Adirondack Astronomy Retreat

2017 Registration Form

JULY 26 – July 30, 2017

Twin Valleys Outdoor Education Center

Lewis, NY

(One family per registration form please)

Please Print:

Name: ______

Address: ______

City: ______State/Province ______Zip/Postal Code: ______

Phone: Best number to call: ( ) ______

EMAIL: ______

Adults: 12 and over Fee:($335) Children: 11 and under: Fee: ($185)

Arrival: 3PM Wednesday 7/26/17 Depart: Noon Sunday 7/30/17

6PM evening meals (W, Th, Fr & Sa) Hot Brunch (Th, Fr, Sa)

Housing & personal facilities

Main Lodge: Separate female and male dorms. Each dorm has a shared bathroom facility

6 cot cabin: Approximately 3 campers per cabin. Bathrooms are in the main lodge only

Optional blanket/pillow rental fee of $5 per person

T-Shirts: (1 for each person in your group – a gift from David and Wendee)

Size: Please circle your size

Small Medium Large X-Large XX-Large Other ______

Color: Please circle your choice: (The plan is to use “gem tones”)

Maroon Dark Royal Blue Green/Teal Purple

Emergency Contact (please print clearly)

Name: ______

Address: ______

Best number: Day ______Evening ______

Special dietary or physical concerns:

___ Vegetarian

___ Other dietary requirements/allergies ______

___ Mobility needs

___ Other special needs ______

In the past, individuals with special needs have enjoyed Twin Valleys, however most of the Twin Valley’s property remains wild and undeveloped. Thus, accommodating non-ambulatory individuals presents a serious problem. Additionally, Twin Valleys lacks paved trails and special toilet and shower facilities.

RELEASE FROM LIABILITY

Having chosen to participate in the Adirondack Astronomy Retreat, I hereby release College Auxiliary Services Inc., SUNY Plattsburgh and Jarnac Observatory, its staff members, Board of Directors, and any and all other persons employed by the aforementioned organizations from any and all liability for bodily injury, emotional injury or loss or property.

This release if binding upon my heirs, executors and assigns.

TO BE OFFICIALLY SIGNED ON SITE______

Camper/Parent Signature Date

CANCELATION POLICY

A non-refundable $25 registration fee is required to reserve your space and full payment is due by Monday, July 10, 2017. Reimbursement, minus the $25 registration fee will be refunded for cancellations received on or before Monday July 10, 2017.

ARRIVAL & DEPARTURE TIMES:

Please do not arrive earlier then 3:00PM on July 26. Campers must depart the Twin Valleys site no later than noon on departure days.

Questions? Contact Wendee Levy:

Payment information:

Check or Money Order (US Dollars) or Credit Card Payments

Email or fax a copy of registration form to:

Jarnac Observatory (Checks & Money orders) College Auxiliary Services

PO Box 895 SUNY Plattsburgh

Vail, AZ 85641 Attn: Chris Hobson Whalen

Fax: 520-762-5722 101 Broad St.

Plattsburgh, NY 12901

Fax: 518-564-4092 PH: 518-564-2038

Adult Retreat Fee: $335 X ______$ ______

Child Retreat fee: $ $185 X ______$ ______

Blanket/Pillow fee: $5 X ______$ ______

Optional donation to Sharing the Sky: $ ______

SUB TOTAL: $ ______

Loyalty Reward:$20 discount (Check/M.O.) received by 1/31/17) $ _____

TOTAL PAYMENT DUE: $______

VISA MASTERCARD DISCOVER

Please circle one Credit card payments are billed from CAS, SUNY Plattsburgh

Card Number: ______Exp Date: ____/____

Security Code: ______Amount: $______

Please Print: Information as it appears on your credit card

NAME: ______

Address: ______

City: ______St./Prov. ______Zip/Postal Code ______