Browncoat Ball 2009 Registration Form

"Official seal's out of date, Captain... Harbatkin?"

Already registered? Please see Payment Instructions.

Required Fields

Personal Information

First Name:

Last Name:

Nickname:

What name would you prefer to appear on your badge?

Real Name
Nickname
Both

Date of Birth:

MM-DD-YYYY

How will you be traveling to the Ball?

Live in town
Flying
Driving
Train

Contact Information

Address:

City:

State/Province:

ZIP/Postal Code:

Country:

Email Address:

Primary Phone:

Secondary Phone:

Emergency Contact Person:

Emergency Contact Phone Number:

Additional Concerns

Dietary Restrictions:

Accessibility Concerns:

Medical/Emergency Information:

Other Concerns/Comments:

Track Option

Choose One:

	Drawn Into the 'Verse Portlanders share our city's love affair with comics.
	Livin' in the 'Verse Explore areas of Portland that overlap with culture that influenced the worlds of Firefly and Serenity.
	The Raggedy Edge If you've never been to Portland, here's your chance to see why we love it.
	NONE (Saturday Ball Only)

Payment Information

Ticket Type:

	Full Weekend Pass $180 (payment plan: 3 installments of $60 due on March 31, April 30, and May 31)
	Full Weekend Pass $175 (discount of $5 if paid in full)
	Saturday Full Day Pass $130
	Saturday Ball Only Pass $80

Money Order

If paying for more than one person, enter their names here:

Policies

I agree to all policies listed on the Policies page.

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Page last modified: Wednesday, 05-Aug-2009 23:54:16 CDT