Vendor Registration

Please complete and return with payment.

Scout Camp Benefit Run

Vendor name: ________________________________________________________

Contact Person: ________________________________________________________

Vendor Address:________________________________________________________

________________________________________________________

Phone: ________________________________________________________

e-mail: ________________________________________________________

Donation for Chinese (silent) Auction [ ]yes [ ] no

Desired Camp for set-up: [ ] J. Edward Mack Scout Reservation
(Route 501, 2 miles North of 322)

   [ ] Bashore Scout Reservation
   (14 miles North of Lebanon, Route 72,
   turn left on Route 443, 2 miles, camp on left)

Please make check payable to MCSA Benefit Ride:
# of sites____ X $40 each = ________

Please complete and return to: MCSA Benefit Ride
PO Box 5201
Lancaster, Pa. 17606-5201

I/We the undersigned hereby myself, my heirs, administrators and assigns waive and release any and all rights and claims of any nature I may have against the Pennsylvania Dutch Council, J. Edward Mack Scout Reservation, Bashore Scout Reservation, the Boy Scouts of America, Mill Creek Sportsman Association, and others sponsoring or connected with this event, their officers, employees, agents, representatives, successors, and assigns, for any and all injuries or damages of any nature which I may suffer while taking part in any activity connected with this event, and will indemnify and hold harmless from any claims for damages or injuries I may suffer, or cause others to suffer.

Signed: _____________________________________________________

Title: _________________________________________________


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