Potlatch 15 Membership Form

• Memberships in Potlatch 13 are available at the following rates:
  • $45 (will be higher at the door)
  • $20 for people aged 6 to 18. (Under 6 free when accompanied by an adult.)
• Make checks payable to "Potlatch 15".

Please print out this form, fill it out, and mail it with your payment
to:

        Potlatch 15 2006 
        c/o S. Tompkins
        PO Box 25075
        Seattle, WA 98165 



List any additional names and addresses on the back or on a separate
sheet.

Name _____________________________________________________________

Address __________________________________________________________

City/State _______________________________________________________

ZIP/Postal Code __________________  Phone ________________________

Alternate Badge Name _____________________________________________

E-Mail Address ___________________________________________________

Please tell us where you found out about this Web page:

__________________________________________________________________
 
  [] I want ___ t-shirts at $15 each, size M,L,XL,XXL,XXXL,XXXL,
     (to be picked up at the convention)
  
  [] I want ___ banquet tickets at $22 each (to be picked up at
     the convention) 

  [] I would like to participate in the writers' workshop

  [] Tell me about how to create or receive a sponsored membership

  [] This is an interesting topic to talk/write/act/dance/sing
     /sketch/kvetch about at Potlatch: ___________________________

     _____________________________________________________________

     _____________________________________________________________


Amount received:____   Check number:____ 	


Other information requested/comments:

__________________________________________________________________

Return to the Potlatch 15 home page

This page created and maintained by Anita Rowland