|
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.) |
| William Shatner ($80) |
______ |
$_______ |
| Amanda Tapping ($55) |
______ |
$_______ |
| Brent Spiner ($45) |
______ |
$_______ |
| Saul Rubinek ($45) |
______ |
$_______ |
| Eddie McClintock ($45) |
______ |
$_______ |
| Teryl Rothery ($45) |
______ |
$_______ |
| Greg Evigan ($35) |
______ |
$_______ |
| Vic Mignogna ($30) |
______ |
$_______ |
| Julie Caitlin Brown ($30) |
______ |
$_______ |
| Shatner/Evigan combo ($95) |
______ |
$_______ |
| Spiner/Rubinek combo ($70) |
______ |
$_______ |
| Rubinek/McClintock combo ($70) |
______ |
$_______ |
| Spiner/Rubinek/McClintock super combo ($90) |
______ |
$_______ |
| |
Teal Shore Leave Polo Shirt
(offered by pre-order, to be picked up at the convention)
Sizes S-2XL: $35; Sizes 3XL-4XL: $40; Sizes 5XL-6XL: $45;
Shirt is Teal with Gray Lettering
|
| _______ |
______ |
$_______ |
| _______ |
______ |
$_______ |
|
Official Shore Leave 35 Bunny ($10)
(Includes this year's shirt, pre-orders to be picked up at the convention.) |
______ |
$_______ |
Official Shore Leave 35 Bunny Shirt only ($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:
___________________________________
___________________________________
|
Events:
Afternoon Tea ($15)
Limited to 40 attendees, includes
craft activity. |
______ |
$_______ |
| Pre-Tea Craft only ($5) |
______ |
$_______ |
Workshops:
| All-Kinds-of-Writing Workshop (free) |
______ |
$_______ |
|
US funds only!
|
|
Total Enclosed: $_______
Mail this form to: Shore Leave, PO Box 6809, Towson, MD 21285-6809.
|
Please be certain to review our Refund Policy.
Photo publicity notice.
