Potlatch 19  - Deca Hotel, Seattle, WA
March 5-7, 2010
Registration - Membership Form

For more information or to pay on-line:  www.potlatch-sf.org

Please make checks payable to:  Potlatch.
 Send to:  Potlatch 19, c/o Suzanne Tompkins,  PO Box 25075, Seattle, WA 98165

We will not share your personal information with any organization other than the next Potlatch conference committee

First Name ____________________ Last Name ____________________

Badge Name (if different than first and last name)

___________________________________________________________

Street Address (optional)_______________________________________

City, State, Zip _______________________________________________

E-mail (required)_______________________________________________
(Email is our main way of contacting people.  If you prefer, let us know and we can send info to your street address.)

Membership / Registration:

Price

Number

  

Amount Enclosed:

     Regular

$65

    

$

     Youth (ages 7-17 years)

$25

    

$

     Child (6 and under)

Free

    

$           0

Extras:

        

   T-shirt (specify size below;
    sizes and quantity are limited)

$15

    

$

   Brunch Banquet

$30

    

$

   Writers Workshop (please contact Mary Kay Kare at
      workshop@potlatch-sf.org for more information)

$15

    

$

 
Dealers Table (please contact Liz Copeland and Suzle Tompkins at
   dealers@potlatch-sf.org before paying; Fee includes one  table and one membership).

 $80

   

$


TOTAL Enclosed:

      

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please check if you are interested in:
    Volunteering                          ____
     Participating in the program   ____

T-shirt Size

Size

M

L

XL

2XL

3XL

4XL

Number you want: