Note - my apology for doing this as a "Cut and Paste" from my files. For some reason I cannot upload the properly formatted forms as an attachment. I keep getting an error message either when trying to attach as a word.doc or a pdf.
Feel free to copy and paste this form as disjointed as it looks or give me your email and I can send you the properly formatted form.
2021 Annual DSSG Spring Scrimmage
(a function of the Deep South Star Gaze)
White Horse Christian Retreat Camp – May 4th – May 9th, 2021
ADDRESS _____________________________________(City) _____________________State)_____ (Zip)_________
TELEPHONE ( ) CLUB AFFIL. (if any) _______________________ EMAIL ________________________________________________
***Vaccination Status – please check appropriate box Vaccinated for COVID 19 YES _______ NO _________
1. Registration Fee – NONE, all fees are for housing, camping and meals
2. Lodging Reservation Choices - Select desired lodging type (2a, 2b 2c or 2d) if staying on-site
2a) Bunk Reservations (note – linens and towels are not provided, please bring your own. Please bring your own blankets too.)
Rate # of people Amount Due
Tuesday (5/4) $35.00 per person X _____________ = ______________
Wednesday (5/5) $35.00 per person X ______________ = ______________
Thursday (5/6) $35.00 per person X ______________ = ______________
Friday (5/7) $35.00 per person X _____________ = ______________
Saturday (5/8) $35.00 per person X _____________ = ______________
*** Note – please indicate above if you have had your COVID vaccination(s) particularly if requesting bunk space. Bunk space will be assigned based upon vaccination status. One or more bunk houses will be for vaccinated attendees and one or more for non-vaccinated attendees.
Bunk Reservations Total $ ____________
2b) Camper, RV or any other vehicle overnight: Reservations – Electrical hookup for rv’s and campers in designated areas only. If tying into a breaker for a camper or rv or otherwise staying overnight in a camper, rv or other vehicle the fee is $35 per night. There are no sanitary hook ups for campers and rv’s. Generators can be used only in designated areas outside of the “Arena Field”. Picnic canopies are permitted on the observing field in compliance with our Light and Parking Rules.
Rate (per night) (Add $5 for # people more than 2) Amount Due
Tuesday (5/4) $35 per rv, camper or any other vehicle overnight if not in a bunkhouse
Wednesday (5/5) $35 per rv, camper or any other vehicle overnight if not in a bunkhouse ______________
Thursday (5/6) $35 per rv, camper or any other vehicle overnight if not in a bunkhouse
Friday (5/7) $35 per rv, camper or any other vehicle overnight if not in a bunkhouse
Saturday (5/8) $35 per rv, camper or any other vehicle overnight if not in a bunkhouse
Camper, RV or any other vehicle overnight: Reservations Total $ ____________
2c) Day Use Fee – This fee only applies to those who chose to come up for a day only and leave that night,
No overnight lodging of any type needed – Day use fee is $10 ……………..Total $ ___________
2d) Tent Reservations – For those registering for the DSSG Spring Scrimmage who would prefer to stay in a tent, the fee is $15 per tent per night. This is a per person charge except for married couples or parents with children. ($15 per tent for married couples or families, $15 per person if not related)
# of People Total per Night
____________ = ______________ Tuesday, May 4th
____________ = ______________ Wednesday, May 5th _____________ = ______________ Thursday, May 6th ____________ = ______________ Friday, May 7th ____________ = ______________ Saturday, May 8th
Tent Reservations Total $ ____________
3. Meals - we do not have a meal plan for the Spring Scrimmage like we do in the fall for the Deep South Star Gaze. Carol does do a snack bar at about 8 pm. Burgers, hot dogs, fries, etc. will be available. Pay for those as you order them. Drinks will be available too. Coffee all day. You will also be able to use the microwave. The Country Diner should be open for breakfast and lunch. Bring plenty of your own snacks.
4. Raffle Prizes – We will do raffle prizes like we did last year. Prizes of equivalent value to what we take in. if we take in $100 we will have a prize or prizes worth $100, if $200 taken in, a $200 prize or prizes, etc. Raffle Tickets - $5.00 each or 6 for $25.00 – Purchase on site
Email me at email@example.com if you have any questions or for reservation verification
Total of sections 1 thru 4 TOTAL REMITTED $___________
All checks (no cash) should be made payable to “Barry Simon” and mailed to:
Barry Simon, DSSG Director
842 Crystal Street
New Orleans, LA 70124
Deep South Spring Scrimmage 2021
RELEASE OF LIABILITY
I, , of
(print name) (city and state)
in consideration of my fee form being accepted for the 2021 Deep South Spring Scrimmage, I hereby irrevocably covenant, promise and agree to relieve, release and hold harmless the DSSG, it's organizers, and workers from any and all losses, claims, expenses, law suits, costs, demands, damages or liabilities, whether joint or several or of whatever kind or nature related, or from any sickness, infection, injuries and / or losses, up to and including accidental death or death due to illness attributable to any cause (including COVID 19) which may occur to the undersigned registrant or his family, or any third person or party for whom the undersigned may be legally responsible while attending the 2021 DSSG Spring Scrimmage.
I further agree to indemnify any party indicated above should such party suffer any claims, liabilities, losses, demands, causes of action, law suits and expenses (including attorney fees), caused directly or indirectly by my negligent or intentional acts, or failure to act, or if such acts or failures to act are directly or indirectly caused by any person in my family while participating in the DSSG Spring Scrimmage 2021.
It is understood that the DSSG Spring Scrimmage is held at the White Horse Christian Retreat Camp located near Sandy Hook, Mississippi. It is understood that the above named event commences at 12 noon on Tuesday, May 4th, 2021 and runs until 12 Noon on Sunday, May 9th 2021. As this is a rural area with a number of events held out of doors and in and around motor vehicles and in the presence of large numbers of other participants, certain dangers and perils are understood and accepted by me in registering for and attending this event. SPECIFICALLY I HOLD HARMLESS THE DSSG, IT'S ORGANIZER(S), THE WHITE HORSE CHRISTIAN RETREAT CAMP AND ANY OTHER REGISTRANTS WHO MAY VOLUNTEER THEIR TIME AND EFFORTS WITH THIS FUNCTION.
I further agree to abide by all rules established by the DSSG and its organizers as specified in rules established for the event.
The White Horse Christian Retreat Camp has a prohibition against alcohol use on White Horse Christian Retreat Camp grounds. We are obligated
to be aware of this prohibition. Act prudently.
I hereby waive any and all claims against the DSSG, IT'S ORGANIZERS, THE WHITE HORSE CHRISTIAN RETREAT CAMP AND ANY OTHER REGISTRANTS WHO MAY VOLUNTEER THEIR TIME AND EFFORTS DURING THE COURSE OF THIS FUNCTION for injury, death or personal property damage or theft in excess of my personal insurance coverage, except in matters of gross neglect or criminal action by either the DSSG, the White Horse Christian Retreat Camp, it's organizer and volunteers. In any incident involving other registrants outside of the actual management of the DSSG, those registrants will be directly responsible for and shall be held accountable for their actions.
My signature on this form also indicates agreement and acceptance on behalf of all minor children (under 18 years of age) under my care in attendance.
________ (initial here) I have received a copy of the DSSG Light and Parking Rules, in force during the Deep South Star Gaze Spring Scrimmage and will abide by them.
*Name Signature Date
* Note - A separate Release of Liability form must be completed by each attending member of your family, age 18 and over.
Additional names of minors (under 18) attending______________________________________(age) _________
Note - Registration is not complete until this form is completed and submitted with your Fee Form.
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