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2008 Advocacy Day Registration

Prefix		*
First Name		*
Last Name		*
Suffix		(e.g. Jr., M.D., Ph.D.)
Home Street Address		*
City		*
State		*
Zip Code		*
Daytime Telephone		*
Mobile Telephone
Email Address		*
Name of your U.S. Representative		Don't Know? Click here to look it up.

LFA Chapter Affiliation		*
If you are not affiliated with a LFA Chapter, are you a member of another lupus organization?		Yes Name of Organization:
Are you a health professional or medical researcher?		Yes Institution:

Which events will you attend?
I will attend all scheduled events
(If you will not be attending all events, please indicate below which events you will attend)

*Monday, March 10*
Orientation, 2:00 p.m.
Reception, 6:00 p.m.
Dinner, 7:00 p.m.

*Tuesday, March 11*
Breakfast, 7:00 a.m.
Scheduled Meetings on Capitol Hill
Luncheon, Noon
Debriefing, 4:00 - 6:00 p.m.


Check if you will be using a wheelchair or motorized cart. (You must make your own arrangements to secure this equipment.)
Check if you need a sign language interpreter
How many times have you attended an LFA Advocacy Day?

Emergency Contact Information:
First Name		*
Last Name		*
Contact's Daytime Telephone		*
Contact's Evening Telephone
Contact's Mobile Telephone

Registration Fee - $35 per person (Everyone must be registered.)
Payment Type		*
(If you are paying by check, please skip the section below and proceed to Submit.)

Credit Card Information:
Credit Card
Account Number		(Numbers Only, No Dashes or Spaces)
Expiration Date
Name on the Card
Billing Address
City
State
Zip Code



Submit to Complete Registration:

Please verify that all of the above information is correct before clicking on the submit button. Please click submit only once to avoid duplicate charges. Once you have submitted your registration information, a confirmation message will be sent to the email address that you provided along with a copy of this form for your records.