2015 “Back to the Beach” Corvette weekend Liability Release & Balance Due Form June 12th – 14th , 2015 In order to get our orders in for the Embroidered Shirts and also to assign lodging rooms We need your remaining balance to be received NLT April 1, 2015 Thank you for your cooperation and continued support Lodging & Meals Reg. Room $425.00____ Kitchenette $445.00____ Waterfront (if available) $500.00____ Please add $65.00 per night if you are coming for Wed & Thursday evening or just Thursday. This is for lodging only Wednesday $65.00____ Thursday $65.00____ Sandpiper Motel Extra Night is $TBD ______ Events Please indicate which events you are planning on attending. Thursday Clam Bake 1:30 PM ($30.00 per person), how many ____ X $_______ = Total $_________ Thursday evening Cruise-in (This is a pay as you go event)...………... _______ Saturday Corvette Fun Display (included in basic package)….……....._______ Saturday Corvette Parade (included in basic package)...…….……...…_______ Basic package $_________ + Additional night/s (optional) $________ + Clam Bake (optional) $________ Minus previous deposit $_________ Balance Due $__________ (Note: Balance due does not include Wed or Thur, please add if you are arriving early) Long Distance Award – Longest distance one way, write your mileage down when you leave home. Embroidered shirts: (circle one per person) Men’s SM M L XL XXL….XXX $3.00 Extra Women’ SM M L XL XXL….XXX $3.00 Extra Name, information, and Liability release (Please fill out the following information) Name: _____________________________ Name: _____________________________ Street: _____________________________ City: ___________________State: _____ Zip:__________ Home phone (optional): ________________________ Cell Phone (optional):_____________________ E-mail address:_____________________ Club Affiliation (optional):___________________________ Liability Release statement: We/I the undersigned release Ralph Quaglietta, Sandie Bergeron, and all sponsoring parties, including the City/Town of Old Orchard Beach from any and all Liabilities incurred while in attendance of this event, June 12th thru the 14th of 2014. (Both must sign & date) Print your name ____________________________Signature______________________Date__________ Print your name ____________________________Signature______________________Date__________ Please remit your payment to: Ralph Quaglietta P.O. Box 1379 Salem, NH 03079 Please visit http://back2thebeach.net for all the latest information