Registration

INSTRUCTIONS: To register for a Butchmanns Experience event, enter this form and review the following:

Participants must be a minimum of 18 years old to participate. Legal ID will be verified upon arrival.
This event includes physical movement and exertion, including SM activities. You are solely responsible for the health, safety and care of your own person. Signed waiver forms are required.
All information provided on this form and throughout the weekend is held in the highest confidence.
Write legibly and verify email address. Confirmation of registration will be sent via email.

PERSONAL INFORMATION

Laste Name *

First Name *

Date of Birth *

Month

Day

Year

Preferred Name for the Event *

Email *

Address *

City *

State *

Zip *

Phone *

Phone

EMERGENCY CONTACT

(someone who is not attending the same event)

Name *

Relationship *

Phone *

EVENT INFORMATION: Which event do you wish to attend? (visit our Schedule page for event details)

Which event do you wish to attend? (visit our Schedule page for event details)

First Choice

Title

Location

Date

Month

Day

Year

Alternate

Title

Location

Date

Month

Day

Year

HEALTH INFORMATION

Contact your health care provider with any questions about your health status.

List any medical conditions or health considerations you have that you would like the hosting organization to be aware of, including current medications (N/A if not applicable): *

List any allergies - food, medications, latex, metal, etc. (N/A if not applicable) *

List any dietary* restrictions or preferences (N/A if not applicable) *

* We will do our best to provide for your dietary needs, however we can not guarantee that special diets will be accommodated. You are welcome to bring any specialty foods for your own use.

EVENT FEES

To be paid in advance and enclosed with the printed application. (select appropriate fee) Payment of Fees at least two weeks prior to event start date reserves your place for the weekend.

First-Time Participant (Phoenix)

$250 – early registration

$275 – within last 4 weeks prior to event start date

Repeat Participant (Phoenix)

$200 – early registration

$225 – within last 4 weeks prior to event start date

First-Time Participant (Oregon)

$300 – early registration

$350 – within last 4 weeks prior to event start date

REFUND POLICY

Participant is eligible for full reimbursement if weekend event is cancelled.

Cancellation up to 4 weeks prior to event	100% reimbursement of event fee
Cancellation between 2 and 4 weeks of event	50% reimbursement of event fee
Cancellation within 2 weeks of event or no-show	0% reimbursement of event fee

AUTHORIZATION

I certify that I am of legal age to attend this event and my payment is enclosed.

Amount paid $

Check #

Send an email notification to registration@butchmanns-experience.org when you mail your fee, make check out to Butchmanns Experience and mail to PO Box 13531, Tempe, AZ 85284

Money Order #

Send an email notification to registration@butchmanns-experience.org when you mail your fee, make money order out to Butchmanns Experience and mail to PO Box 13531, Tempe, AZ 85284

Pay by Credit Card

Yes

You will get a "Square" invoice (do not give your CC number here)

Printed Name

Verify Email *

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

What code is in the image? *

Enter the characters shown in the image.