The 2010 Firefly Housewarming

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Conference Registration

Required field1 Legal Name
Required field2 Preferred or Magickal Name (for name tag and registration purposes) 
Required field3 Email Address
Required field4 Street Address
Required field5 City, State, and Zip Code
Required field6 Country
Required field7 Phone Number (including area code, and if outside the U.S., include the country code)
Required field8 Date of Birth (MM-DD-YYYY)
9 If you are not staying the entire conference, select the event dates in which you will participate:





10 How did you hear about this event?
11

List any medical conditions of which we should be aware:
Required field12 Emergency Contact Name
Required field13 Emergency Contact Phone Number
  By submitting this form, I understand that I am expected to abide by any rules set forth by The Firefly House Warming planning committee.