2015 SPA Field Trip                      Ohio Moundbuilders

June 4-7, 2015

Registration Form  (one form per person)

Print and Mail along with deposit by May 15.

to

Ken Burkett, SPA Treasurer, 2717 Brookville Street,  Fairmount City, PA 16224
 

Name

 

Address

 

 

Phone Number                                                               SPA Member       Yes                No

 

Occupancy   (Circle one)                        Single                                  Double

 

Name of second person for Double Occupancy :

 

If you will you be a guest of an SPA member, what is their name:

 

Do you need a room for the evening of June 4?                       Yes              No

 

Total Amount Due by June 4: (circle one)

 $250 SPA member/first guest (Double Occupancy) 

 $350 SPA member/first guest (Single Occupancy) 

 $300 Non -SPA member (Double Occupancy)

 $400 Non-SPA member (Single Occupancy)

                           Deposit Amount  Enclosed  (Minimum amount is $100 by May 15)

Dietary Restrictions (Please Describe)

 

 

 

Health Conditions ({Please list those that may limit your activities while on this trip; you should expect moderate physical activity)

 

 

 

 

 

Emergency Contact

Name:                                                                                                            Phone Number:

 

 

 

 

 

Enter Name of Person Attending

You can submit your non-refundable deposit by credit card using PayPal, but you must mail or scan and email a completed form to the SPA treasurer: kenburkett@comcast.net