SerpentStone Gathering Pre-Registration Form

Samhain 2005 Gathering

Please fill out and submit one form for each person who will be attending the gathering. (This includes all children.) This information is used to pre-print your Gathering Release Form, which will save you time when you arrive at registration and check in. Your registration will be valid only after your check or money order has been received and processed, and it must be postmarked BEFORE the appropriate deadline date.

If you would prefer to mail in your pre-registration, feel free to fill out the form and print it without submitting it. You will need to send your check or money order (made out to SerpentStone) along with the printout of the completed form to:

SerpentStone
P.O. Box 9296
Knoxville, TN 37940

Gathering Fee: (Please note the cost change for the 4-day Gathering)

$10.00 per child^* ages 12-16 (plus your feast contribution and 2 hours of community service)
if postmarked and paid before October 20, 2005

$20.00 per person^** over 16 years of age (plus your feast contribution and 2 hours of community service)
if postmarked and paid before October 20, 2005
(Pre-registered / Pre-PAID for above prices, please)

$30.00 per person^** after October 20, 2005 and at the door (plus your feast contribution and 2 hours of community service).

^*Children under 12 are free. Anyone under 18 must be accompanied by a guardian. If not a custodial parent, the guardian must be responsible for the minor, and have a written permission statement from the parent, which must be presented at registration immediately upon arrival.
^**Work-scholarships (in which the registration fee is waived in return for a number of extra work shifts) are available for those for whom finances are an issue. Contact the Registration Coordinator to make arrangements.

All gatherings fees are non-refundable. However, if you have pre-paid and are unable to attend the gathering, you may contact us before the gathering, and your fee can be applied to a future gathering.

FILL IN ALL FIELDS PLEASE
**Denotes a required field.


This is my first gathering. I understand that there will be someone to welcome me to the gathering, to introduce me to some folks, and to show me around.

**Your Legal Name
Nickname/PIC:
Group/Coven Affiliation:
**Mailing Address Line 1:
**Mailing Address Line 2:
**City:	**State	**Zip
Phone Number:
**Email Address:	(needed for confirmation of pre-registration)
**E-mail Format
Home Page Address:
**Birthdate:	Month	Day Year

Dietary Preference: (please select one)	Vegetarian	Omnivore

Emergency Contacts: (mundane names please)
**Onsite
**Offsite		**Phone
Health or Medical Concerns: This is where you tell us about any health problems, food allergies, other allergies and the like that you might have.

Special Skills: Are you CPR certified? A doctor or nurse or other medical professional? Do you know American Sign Language or a foreign language? Please let us know what skills you might have that could help us out.

I would like to register as a merchant at this gathering. I understand that this is an additional $10.00 added to my registration price, and have included it with my pre-registration payment. I also understand that I have to fill out a Merchant Contract before I am allowed onsite.

This form is for a Child Under 12
Parent or Adult Responsible for Child:
Minors not accompanied by their parents must have a signed permission slip from at least one parent and be supervised at all times by their guardian(s).

Comments or Questions:

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