Pacific Media Expo 2004 Masquerade Participation Form

(Please print from your computer and submit it to the Masquerade Desk when you check in.)


Participant's Name: ___________________________________________________________


Group Name: ___________________________________________________________________


Date of birth: _______________________________   Age: _________________________


Phone Number: _________________________________________________________________


Address: 

________________________________________________________ 

________________________________________________________ 

________________________________________________________ 

________________________________________________________


I, ____________________________________,  grant permission for ___________________________
to participate in the Pacific Media Expo 2004 Masquerade events taking place
May 29 - May 31, 2004. I further give my consent to Pacific Media Expo to acquire
emergency medical treatment from competent medical personnel/facilities should
that become necessary for any reason.



Guardian's Name (Print): ____________________________________________

Guardian's Signature: ______________________________ Date: __________ 

Guardian's Relation to Applicant: ___________________________________