Rolling Roads 
1605 Elm Shore
Port Byron, IL 61275

A deposit of $325.00 per person is required to guarantee your registration. Upon completion of this registration form you will be given the opportunity to make a deposit via credit card or PayPal, you may also mail your registration to the address above and include a deposit check at that time. Registration forms received that are not followed by a deposit and valid credit card information (required to secure full payment) will not be guaranteed a spot until such information is received by Rolling Roads.

* Field is required to complete registration

	Trip Detail	Base Trip Cost (per person) $
Trip Name:
Trip Date:

Participant Information You may register up to 5 participants if a primary participant will be paying for the entire group (such as a Family, Couple or group vacation.) Participants paying seperately must complete a seperate registration
	Name	*Gender		Age	Can Swim?
*Primary Participant (Participant  responsible for full payment and main contact person for the group)		Male	Female	< 14 15-17 18 - 59 60+
Participant 2		Male	Female	< 14 15-17 18 - 59 60+
Participant 3		Male	Female	< 14 15-17 18 - 59 60+
Participant 4		Male	Female	< 14 15-17 18 - 59 60+
Participant 5		Male	Female	< 14 15-17 18 - 59 60+
Total: $
*Rolling Roads requires gender and age information at time of registration for equipment planning purposes.

Registration Contact Information
eMail:	*Primary: *Confirm Primary:  Secondary:
Telephone:	*Primary:                   Home:                Cell:
*Address line 1
Address Line 2
*City:  *State/Province:  *Zip:  *Country:
Preferred Method of Contact: Home Phone Work Phone Cell Phone Home eMail Work eMail
How did you hear about Rolling Roads? The Metal Cowboy Google Yahoo Other Search Engine Travel Agent A Friend Magazine Ad Outdoor Expo

Lodging & Travel Preferences
	Options	Rate
Standard Double Occupancy Tent	N/A	Included	Rolling Roads provides a 3-4 person tent for 2 Persons
Private Tent (single occupancy)	Upgrade	+ $100	For more than 1 private tent please indicate number needed in Special Needs below. (Cost is $100.00 per tent)
Special Needs or requirements (No HTML or links)
I will be arriving by:	Airplane Automobile Train Bus Other
If arriving by automobile, will you require extended parking?	Yes   No
I Plan on arriving:	First day of trip 1+ days before start of trip
I plan on departing:	Last day of trip 1+ days after end of trip
I would like Pre and/or post trip lodging availability and rate information:	Before my trip After my trip Before & After my trip No Thanks

Deposit - Release & Liability Waiver

PLEASE NOTE: A minimum deposit of $325.00 per person is required to guarantee registration. Upon completion of this registration form you will be given the opportunity to make a deposit via credit card or PayPal, you may also mail your registration to the address found at the top of this form and include a deposit check at that time. Registration forms received that are not followed by a deposit and valid credit card information (required to secure full payment) will not be guaranteed a spot until such information is received by Rolling Roads. Further, each participant will be required to sign and return a release and waiver statement certifying that they are in good health and physically able to participate in the selected tour. You must return this release and waiver in order to complete your registration, no exceptions will be made.  We recommend consulting your doctor if you are not absolutely certain of your ability to complete this trip. *I/We understand that I/We must sign a release and waiver of liability and certify that we are in good health  in order to complete registration for this trip. Coupon Code:

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Trip Cost Estimator (Does not include taxes or promotional discounts)		Registration Submission
Trip Base Cost: $		Enter Verification Code: Total Cost of trip including taxes and promotional discounts will be calculated, and an invoice and receipt will be emailed to you within 72 hours of completion of registration and confirmation of deposit.
Equipment Extras: $
Grand Total: $

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