2025 Central Region Registration Form

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Start Date: 2025-05-09       Departure Date: 2025-05-17

Coachlight RV Park


Sponsor(s):

Host: Nita Taylor     Phone: (501) 250-6585     Email: philnita.taylor@gmail.com


Muster Costs:

Single Cost: $0.00   Couple Cost: $0.00   Couple + Guest Cost: $0.00   Camping/night: $37.50  

Registration

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

Pilot:   SMART#:

Copilot:   SMART#:

   

Pilot's Email:

       

In Case of Emergency (ICE) Contact Information

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

   

   

RV Information

       

       

I tow a vehicle behind my motor home.  

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.”

     

  37.50/night

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

Tours

  Tour#1 Ladies luncheon - Cost: $0.00

  Total: $

  Tour#2 Mens luncheon - Cost: $0.00

To be held at the Gift Horse Restaurant in Foley   Total: $

  Tour#3 Golf - Cost: $0.00

  Total: $

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.

Name Signature Date
Pilot:
Copilot:
Guest:

This event does not have a muster fee. Please mail a copy of this form to Nita Taylor, 2 Chapman Lane, Little Rock, AR 72211.