2011 Lupus Foundation of America Butterfly Gala Media Registration


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Thank you for your interest in covering the Lupus Foundation of America’s Butterfly Gala. The LFA appreciates your support in helping to bring awareness of lupus, and the LFA’s mission of finding the causes of and cure for lupus and providing support, services and hope to all people affected by lupus.

Only pre-approved and credentialed media will be admitted to The Butterfly Gala. Please complete the form below, and we will review your request. We will do our best to accommodate your request.

We will notify you by phone or email once we have made a decision regarding your coverage of The Butterfly Gala.

If you have any questions, please feel to email Maggie Maloney at Maloney@lupus.org.

Part One - About the Registrant:
Prefix:
First Name:	*
Last Name:	*
Suffix:
Position/Title:
Organization:
Mailing Address:	*
City:	*
State or Province:	Please use two-digit state code for US
Zip or postal code:
Daytime Telephone Number:	*
Fax Number:
Your Email:	* Example: yourname@domain.org

Part Two: About the Media Outlet:
Media Type:	*
For Internet Media Only (provide URL, average # monthly unique visitors):
List Other Individuals Who Will Accompany You (e.g. videographer, photographer, field producer):
Please tell us briefly who you are most interested in interviewing, and what aspect of the event you are interested in covering:	*
List Special Needs (e.g. multibox, electric):
Other Requests / Needs:

Please review the information you have entered. When ready to forward your information, please click the "submit" button. DO NOT DOUBLE CLICK.