2012 Media Days Member Registration

    *First Name:

    *Last Name:

    *Title

    *Street Address:

    *City:

    *State:

    *ZIP Code:

    *Work Phone:

    Home Phone:

    Cell Phone

    *Email:

    *Primary Media Outlet:

    Additional Outlet

    *Emergency Contact Name:

    *Emergency Contact Telephone:

    Where will you be staying:

    Attending Ride & Drive:
    yesno
    Attending On-Track Event:
    yesno
    *Attending Banquet:
    [radio banquet* "yes" "no"]
    *Menu Selection:
    [select menu* include_blank "Beef" "Chicken" "Vegetarian"]
    Bringing Guest:

    Guest Name:

    Guest Attending Tuesday Lunch:
    yesno
    Guest Attending Wednesday Lunch:
    yesno
    Guest Attending Banquet:
    yesno
    Guest Menu Selection:

    * Required Information

    OK, NOT DONE YET, NOW PROCEED TO SECTION 2 TO BOOK YOUR MEDIA DAYS REGISTRATION AND PAY.