Start Date: 2024-11-14       Departure Date: 2024-11-14

Hideaway Pizza

• Address: 326 N. Main St., Crestview, FL 32536
• Phone:
• For Reservations Contact:

Sponsor(s): White Sands Panhandlers

Host: Chuck Kuzma     Phone: (850) 803-8761     Email: ckuzma116@cox.net

Muster Costs:

Single Cost: $0.00   Couple Cost: $0.00   Couple + Guest Cost: $0.00  

An entry in all fields shown in the registration form is required.

Pilot:   SMART#:

Copilot:   SMART#:

Home:   Pilot's Mobile:   Copilot's Mobile:

Pilot's Email:

Street

City     State     Zip

In Case of Emergency (ICE) Contact Information

Please provide at least one emergency contact other than your Copilot.

Notify:   Phone:   Relationship:

Notify:   Phone:   Relationship:

RV Information

RV Type:         Make:

Model:         Length:

I tow a vehicle behind my motor home.   Total length of tow and towing vehicles:

Attendees:   One Person $0.00.00   Two Persons $0.00.00   Two plus Guest $0.00.00

I (We) are first time attendee(s).

Guest Name:   Enter guest first and last names or “None.”

Planned Arrival:       Planned Departure:

Handicap Parking         30 Amps   50 Amps

Do you or your traveling companion use any of the following, cane, walker, electric wheel chair, scooter, C-PAP?  

If Yes, please indicate which one(s):

Special Diet Needs  

His:  

Hers:

  I will volunteer to help at the Muster

Liability Release

In consideration for my (our) attendance, I (We) hereby release and agree to indemnify and hold harmless SMART, its officers, directors, employees, agents, successors, and assigns from any and all liabilities, claims, losses, and/or damages arising from my (our) attendance at this event.

All attendees must read and sign this form.

This event does not have a muster fee. Please mail a copy of this form to Chuck Kuzma, 116 Duke Drive, Niceville, FL 32578.