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Baxter State Park Please print this form and mail to the above address. This Form must be mailed in with request and received by the Reservations Office at least two (2) weeks prior to departure. Trip Dates: Number in Party: Destination, Proposed Itinerary, and Routes: WINTER CAMPING PARTY NAMES LEADER'S NAME:________________________________________CO-LEADER #1:__________________________________________ CO-LEADER #2:__________________________________________ TEAM MEMBER:_________________________________________ TEAM MEMBER:_________________________________________ TEAM MEMBER:_________________________________________ TEAM MEMBER:_________________________________________ TEAM MEMBER:_________________________________________ TEAM MEMBER:_________________________________________ TEAM MEMBER:_________________________________________ MOTOR VEHICLE INFORMATION (FOR VEHICLES PARKED AT PARKING LOT): MAKE/COLOR/PLATE #:__________________________________ Type of payment: Check #_______________ # VISA or MASTER CARD #___________________ expiration date:____________________ -------------------------------------------------------------------------------- LEADER INFORMATION Name: Mailing Address: Home Phone: Work Phone: Prior winter experience in Baxter State Park ? IN OTHER WILDERNESS AREAS? Emergency notification Name: Relationship: Address: Home Phone: Work Phone: I,_______________________, ATTEST THAT TO THE BEST OF MY KNOWLEDGE, ALL MEMBERS ARE CAPABLE AND FIT ENOUGH TO ENSURE OUR SAFE COMPLETION OF OUR PROPOSED ITINERARY. -------------------------------------------------------------------------------- ASSISTANT-LEADER INFORMATION Name: Mailing Address: Home Phone: Work Phone: PRIOR WINTER EXPERIENCE IN BAXTER STATE PARK? IN OTHER WILDERNESS AREAS? Emergency notification Name: Relationship: Address: Home Phone: Work Phone: -------------------------------------------------------------------------------- ASSISTANT-LEADER INFORMATION Name: Mailing Address: Home Phone: Work Phone: PRIOR WINTER EXPERIENCE IN BAXTER STATE PARK? IN OTHER WILDERNESS AREAS? Emergency notification Name: Relationship: Address: Home Phone: Work Phone: -------------------------------------------------------------------------------- TEAM MEMBER INFORMATION Name: Mailing Address: Home Phone: Work Phone: Emergency Notification Name: Relationship: Address: Home Phone: Work Phone: -------------------------------------------------------------------------------- TEAM MEMBER INFORMATION Name: Mailing Address: Home Phone: Work Phone: Emergency Notification Name: Relationship: Address: Home Phone: Work Phone: -------------------------------------------------------------------------------- TEAM MEMBER INFORMATION Name: Mailing Address: Home Phone: Work Phone: Emergency Notification Name: Relationship: Address: Home Phone: Work Phone: -------------------------------------------------------------------------------- TEAM MEMBER INFORMATION Name: Mailing Address: Home Phone: Work Phone: Emergency Notification Name: Relationship: Address: Home Phone: Work Phone: -------------------------------------------------------------------------------- TEAM MEMBER INFORMATION Name: Mailing Address: Home Phone: Work Phone: Emergency Notification Name: Relationship: Address: Home Phone: Work Phone: -------------------------------------------------------------------------------- TEAM MEMBER INFORMATION Name: Mailing Address: Home Phone: Work Phone: Emergency Notification Name: Relationship: Address: Home Phone: Work Phone: |
Source: B.S.P.