Please complete the information below to pay your registration fee by credit card.

FIRST NAME:
LAST NAME:
ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
EMAIL:
2ND PERSON :

Please use the check boxes to indicate the events you will attend (this will help us plan food and beverages for each event):

Breakfast Lunch Dolphin's Party

Early Registration: $25.00 per person. Same Day Registration: $35.00 per person. Registration fee includes Saturday breakfast and lunch, conference materials, and the Dolphin Democrat's Holiday Party Saturday evening. The Saturday afternoon session are free and open to the public.

Please use an additional form to register more than 2 persons.

This will take you to the next screen.

If you would like to pay by check, please print this page, complete the information and send it to:

FLORIDA GLBT DEMOCRATIC CAUCUS
P.O. Box 7492
Fort Lauderdale, FL 33338-7492

Questions may be directed to info@floridaglbtdemocrats.org or give us a call at 877-446-8569.