Name:_____________________________

Badge Name (if different):_______________

Address: __________________________

City/ST/ZIP: ________________________

Phone: ____________________________

E-Mail: ___________________________
___ Please check here if you'd like the registration confirmation and the update sent by email. If you choose this option, you do not need to send a SASE. Please print legibly.

For credit card payments only:
Account #: _________________________

Exp. Date: _______ Circle: MC / VISA

Signature: _____________________________

Adult Weekend Membership ($80) $_______
Teen Membership ($50)
(ages 13-17)
$_______
Youth Membership ($20)
(for children ages 5-12)
$_______
Adult Friday Only Membership ($30) $_______
Adult Saturday Only Membership ($60) $_______
Adult Sunday Only Membership ($40) $_______
Active Military receives a $10 Discount (Must present ID at pickup.)
Supporting Membership ($10)
(non-attending, incl. program book and badge)
$_______
Badge numbers for one day memberships will be numbered after weekend badges.
Total this section $_______

Photo Ops

Photo Ops with our celebrity guests will be offered as they are confirmed.

(All prices are per print.)
Richard Dean Anderson ($85) ______ $_______
Silas Weir Mitchell ($45) ______ $_______
Robert Picardo ($45) ______ $_______
Michael Welch ($45) ______ $_______
Richard Dean Anderson/Robert Picardo combo ($120) ______ $_______
Richard Dean Anderson/Michael Welch combo ($110) ______ $_______
 

Bunnies

Official Shore Leave 36 Bunny ($10)
(Includes this year's shirt for bunny, pre-orders to be picked up at the convention.)
______ $_______
Official Shore Leave 35 shirt for Bunny ($5)
(Shirt only, pre-orders to be picked up at the convention.)
______ $_______

Total this section $_______

Send More Information About:
Masquerade: __ Art Show: __
Blood Drive: __ Filking: __ Gaming: __
Child/Youth Programming: __
Disability Support: __

I Can Help With:
Art Show: __ Registration: __
Security: __ Blood Drive: __
Thursday PM/Mon AM Manual Labor: __
Anything you need: __

Fan Clubs You Belong To:
___________________________________
Fan Panel Topic Suggestions:
___________________________________
___________________________________

Special Events:

Richard Dean Anderson's Saturday presentation ($20).
(Requires a Full-weekend or Saturday-only admission.)
______ $_______
Richard Dean Anderson's Sunday presentation ($20).
(Requires a Full-weekend or Sunday-only admission.)
______ $_______

Workshops:

Workshop details will be published as they become available.

Total Enclosed: $_______ (US funds only!)

Mail this form to: Shore Leave, PO Box 6809, Towson, MD 21285-6809.

Please be certain to review our Refund Policy.

Photo publicity notice.