Virginia Scrapbook Retreats

                                                             Scrapbook Weekend Retreat

Registration Form

Name:_________________________________________________________________________________

Address:_______________________________________________________________________________

City:____________________________________State:_______________________ Zip:______________

PhoneNo.:_____________________________Alternate Phone # :________________________________

Email_________________________________Roommate:______________________________________ Registration: $225.00 total amount per person double occupancy

$325.00 single occupancy

$125 local cropper only no hotel stay included

SELECT PAYMENT AMOUNT:

Deposit $50 due by 7/01/10 balance due by 10/01/10 YES_____________________________________

Payment in full local crop rate$125.00_____________________________________________________

Payment in full $225__________________________________________________________________

Payment in full Single occupancy $325.00_________________________________________________

NOTE: Late fee of $25 added if deposit or payment not received by 7/0109

Crop Room (please list the names of people you wish to sit with; we will do our best to accommodate you)

Table Mates:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Payment Type:

Check – made payable to Mary Full (return check fee $35.00 for any reason plus any adt’l court cost) or Visa MasterCard Discover American Express

Credit Card Information: By completing the information below, you authorize Mary Full to charge the below card the amount specified.

Cardholder Name_______________________________________________________________________

Card No.:_____________________________________________Security code on back of card_________

Expiration Date:___________________________Zip Code:______________________________________

Signature:______________________________________________________________________________

How did you hear about us?

flyer friend Scrapbook Store Internet Email other

NOTE:  A $35.00 return check fee will incur plus any related court fees for any reason a check is returned.

                                                                     Mary Full

                                                                   mertful@cox.net

                                                                     757-287-4774