Registered Name:
(This is the name you will use to register for Astronomicon, aka your legal name.)

Name to be used in program book, panel introduction, and communication:

Mailing Address:
City: State/Province: Postal Code: Country:

Phone Number:
E-mail Address:
(Do you agree for this address to be handed over to other panelists: Yes No
This will allow better preparation. If it's an issue, add a note in the comments.)

Age: 18+ 16-18 0-15

Ideas fo Panels That You'd Like to Speak On:
(List descriptions and any additional information in comments section below.)
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I Have Done Panels at Astronomicon Before: Yes No
If so, which ones:

I Have Done Panels at Another Convention Before: Yes No
If so, where:

Are You Willing to Moderate Panels? Yes No

I Have Moderated a Panel Before: Yes No
If so, where:

I Will Not be Available for Panels During:
(Specify exact dates/times or events. Include arrival time and departure time if during convention hours.)

Panelists You Don't Want to be on Panels With:
(This is kept in the strictest of confidence, we understand sometimes there are personal conflicts
or professional ones that may cause one panelists to not want to be on a panel with another panelist.
That in mind, we will try to see that your request is honored.)

Comments: