Registration Form
| Name _______________________________________ |
Legal Name if different ____________________________
|
Mailing Name___________________________________
|
Address_____________________________________ |
City_________________________________________
|
State/Province_________________ Zip_____________ |
Contact Phone _______________(Please include area code)
|
******(confidentiality is assured)******
| |
POWERSURGE ’98 AT ’92 PRICES... WHAT A DEAL!!!!!!!!!!
Make Out Check or money order (MUST BE U.S. FUNDS) to: Powersurge, Inc and send to:
"Powersurge** PO Box 27684** Seattle, WA 98125-2684"
|
Please Check One |
Deadline |
amount |
|
___Early Registration |
July 15 |
$80.00 |
|
__ Registration |
August 15 |
$95.00 |
|
__ Day Of Conference |
Sept 4/5 |
$120.00* |
|
__ Work Exchange |
July 15 |
$40.00 (deposit)** |
*during registration hours only Friday Sept 4 and Sat Sept 5 SUBJECT TO SPACE
I certify that I am 18 years or older and can present valid female ID when requested. I agree to comply with all POWERSURGE Policies. I assume complete responsibility and will not hold POWERSURGE or any of it's agents liable.
Legal signature____________________________________________
Registration cannot be processed without a legal signature.
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Work Exchange
I have read and understood the work exchange policies. I agree to comply with POWERSURGE policies and fulfill my work exchanged as assigned by the work exchange committee. I understand that should I be unable or unwilling to complete my work exchange commitments, my $40.00 deposit will become non-refundable. I assume full responsibility and will not hold POWERSURGE or any of it's agents liable.
Legal signature____________________________________________________
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Do you have any physical limitations? Explain.____________________________________________________
Local contact phone number_______________________(please include area code)
Arrival Date__________________ Time________
Departure Date________________ Time_________
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Limited housing available upon a first come first serve basis. Need Housing __
Can provide housing __ For how many people ___ Smoking __ No-smoking __
Clean and sober __ Allergies: dog __ cat __ other ________________
Sleeping preferences/availability: Bed __ Futon __ Couch __ Floor __ Shared Bed __
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Please mark your interest in any of the following:
ASL interpreter __ ASL interpretation__
DM at play parties __ years of experience_____
Vendor Information __ Other____________________________________________
