Student Name ____________________________________________________

Address _________________________________________________________

_________________________________________________________

Phone _____________________

E-mail __________________________________________________________

Age ___________ Grade __________

Teacher _________________________________________________________

School __________________________________________________________

School Address ___________________________________________________

___________________________________________________

Permission Slip

Parent or Legal Guardian ___________________________________________

Title of Story _________________________________

All entries become the property of Loscon. They may be displayed at science fiction conventions and Loscon may publish some or all of the entries.

I hereby give ______________________________________ permission to participate in the Student Science Fiction Contest.

Signature of parent or legal guardian

_________________________________________