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: ___________________________________