Save this page, fill it out, and email to registration@philcon.org

Full name (Badge Name) if different Age (if under 16)

Name #1:

Name #2:

Name #3:

Name #4:

Address:

City:

State:

Zip:

Add more name lines above if necessary. All persons listed will be

assumed to be living at the same address. If this is not the case,

please supply the full address for each person not living at the above

address.

Membership type Till 9/15 9/16 - 10/24 10/25 - At the Door

~~~~~~~~~~~~~~~ ~~~~~~~~~ ~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~

Adult $30.00 $35.00 $40.00

Child (age 7-12) $15.00 $17.50 $20.00

Child (age 0-6) Free with paying adult

Babysitting (age 7 or less): $40, plus 2 hours of your time per child.

Babysitting MAY OR MAY NOT BE available this year. Stay tuned.

Number of adults @ $30.00/$35.00: Subtotal: $

# children 6-12 @ $15.00/$17.50: Subtotal: $

Babysitting @ $40.00: Subtotal: $ (if available)

=============

Total: $

Mastercard Visa (choose one)

Name as it appears on card:

Card number:

Exp. date:

Amount:

Email completed form to registration@philcon.org, or (preferred) add signature and mail to:

Philcon Registration

P.O. Box 8303

Philadelphia, PA 19101-8303