Name of Individual/Family: * Total members attending * Email * Phone * $50.00 Flat Rate Registration Fee Select Quantity 1 ADULT or 1 FAMILY - $ 50.00 If rooming with another Adult that is not family, please state Name of roommate and choose double occupancy: CONFERENCE CENTER: The Conference Center
sleeps 3-4 per room with private bath- August 4-7, 2022.
ALL SLEEPING ACCOMMODATION RATES INCLUDE 3 MEALS A DAY WITH EACH OVERNIGHT STAY PER PERSON SINGLE ADULT OCCUPANCY (1 Adult | $159 Per Person One Night): Select Quantity 2 Nights - $ 318.00 3 Nights - $ 477.00
This rate is for one (1) adult in a private room w/ private bath at the conference center.
DOUBLE OCCUPANCY (2 Adult | $127.5 Per Person One Night): Select Quantity 1 Adult 2 Nights - $ 255.00 1 Adult 3 Nights - $ 385.50 2 Adults 2 Nights - $ 510.00 2 Adults 3 Nights - $ 765.00
(Double occupancy = 2 individuals per room)
Children must be accompanied by an adult for duration of stay. A child will be considered the second guest if it is just a one parent and child.
AGES 3-7 ($21.5 Per Person One Night) Select Quantity 1 Child 2 Nights - $ 43.00 1 Child 3 Nights - $ 64.50 2 Children 2 Nights - $ 86.00 2 Children 3 Nights - $ 129.00 3 Children 2 Nights - $ 129.00 3 Children 3 Nights - $ 193.50 AGES 8-12 ($32 Per Person One Night) Select Quantity 1 Child 2 Nights - $ 64.00 1 Child 3 Nights - $ 96.00 2 Children 2 Nights - $ 128.00 2 Children 3 Nights - $ 192.00 3 Children 2 Nights - $ 192.00 3 Children 3 Nights - $ 288.00 AGES 13-17 ($48 Per Person One Night) Select Quantity 1 Child 2 Nights - $ 96.00 1 Child 3 Nights - $ 144.00 2 Children 2 Nights - $ 192.00 2 Children 3 Nights - $ 288.00 3 Children 2 Nights - $ 288.00 3 Children 3 Nights - $ 432.00
Additional Required Information
IS ANYONE N-TUBE or G-TUBE FED (and will NOT be dining on the provided included meals)? Age Name of adult/adults: Name of child/children: Age ADA room required for wheelchair (Conference Center only)? Y or N Select Yes or No YES NO FIRST FLOOR room required? (Conference Center only) Y or N Select Yes or No YES NO FOOD ALLERGIES: Y or N Select Yes or No YES NO ENVIRONMENTAL ALLERGIES: Y or N Select Yes or No YES NO If yes, list allergies: Vegan diet: Y or N Select Yes or No YES NO Gluten Free: Y or N Select Yes or No YES NO SPECIAL DIET other than above required? Any physical limitations (this will help us plan group events)? Select Yes or No YES NO Is there anything special you enjoy doing that can help us plan activities? Select Yes or No YES NO Adults: If attending as a single occupancy camper, would you like to be paired with a same sex adult camper for room sharing, if possible? Y or N Select Yes or No YES NO If you have made rooming arrangements with another adult, please state their name:
Please review the Liability Form. Once reviewed, check ‘I agree’ and initial.
WAIVER AND RELEASE OF LIABILITY AND INDEMNITY AGREEMENT
PLEASE READ THIS DOCUMENT CAREFULLY, BY ACCEPTING THIS AGREEMENT YOU ARE WAIVING CERTAIN LEGAL RIGHTS AND YOU ARE RELEASING THE SPONSORS, PROMOTORS, BENEFICIARIES, AND EVENT MANAGER OF “Many Faces of Moebius Syndrome Camp Moebius” FROM ANY AND ALL LIABILITY.
I hereby waive, discharge, and release the sponsors, promoters, beneficiaries and event managers of Many Faces of Moebius Syndrome (MFOMS) Camp Moebius and The Many Faces of Moebius Syndrome nonprofit, and any and all individuals employed, contracted by, associated with or assisting in the production and management of Camp Moebius from and against any and all liability they have or may be determined to have, whether caused by their negligence or otherwise, concerning any injuries or damages of any kind that I may suffer from my participation in or related to Camp Moebius, including but not limited to, physical or mental injuries, death, medical expenses and property damages.
This waiver and Release of Liability and Indemnity Agreement shall apply to and be binding upon my heirs, personal representatives, and assigns and any other individual or entity acting on my behalf, or acting through subrogation.
I understand that Camp Moebius is an event involving environmental factors, such as, but not limited to; bees, wasps, snakes, insects, wildlife, water, outdoor equipment, campfires and understand the risks associated with participating in outdoor activities. I am relying on my own judgment in assuming all risks of injury and damage and agreeing to indemnify and hold harmless the Indemnified Parties as stated in the foregoing.
This Release and Indemnification is intended to be as broad and inclusive as is permitted by the laws of Indiana. If any portion of this Release and Indemnification is held invalid or unenforceable, it is expressly agreed that the remaining provisions shall continue in full force and legal effect.
If signing as a parent, guardian or agent on behalf of a minor participant, I certify that I have the actual authority to sign the Waiver on behalf of such minor. I also understand and give permission to the Indemnified Parties to use my name or images of my participation in MFOMS Camp Moebius for publicity or promotional purposes, without liability or obligation to compensate me. Select Yes or No YES NO
By providing my email address, I give permission to MFOMS Camp Moebius and its owners to communicate with me via this method. If after the MFOMS Camp Moebius, I wish to remove my email address from the Camp Moebius list I will be able to do so.
I have read, understand, and do voluntarily agree to all the terms of this Release and Indemnification and specifically state that no representations, statements, or inducements have been made to encourage my participation in Camp Moebius. Liability Name Liability Initial
(Please note: a hardcopy will be signed upon check-in for each adult camper/minor camper for file)