Potlatch 16 Membership Form

• Memberships in Potlatch 16 are now $35, by mail until April 30, 2006; More later.
• Children who will be 6-12 at the time of the convention are half price. Children 5 and under at the time of the convention are free. Children must be accompanied by an adult with a membership.
• Make checks payable to "Potlatch 16".

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

        Potlatch 16
        c/o OSFCI
        PO Box 5703
        Portland, Oregon 97228

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:

__________________________________________________________________


Would you like to work on Potlatch 16?
        [] At the Convention   and/or [] On the Planning Committee

[] Do not print/publish my name

[] Just email my progress reports.

Other information requested/comments:

__________________________________________________________________