Registration

Registration deadline is September 1, 2012

Complete the following form and click on SUBMIT to confirm your registration.

Contact InformationFirst Name:

Last Name:

Name for Name Badge:

Name of Institution:

Address:

City:

Select a State:

Zip code:

Phone number:

Email Address:

Confirm your email address:

(Please Note: Your email address is what we use to track your participation in the workshop. Be sure to use the same email address in all forms relating to your workshop participation. This email will also be our primary means of communication with you.)

Cell Phone Number (This information is only used to contact you if there are issues that arise during your transit to or from the workshop.)

Laptop Computer Please check here if you ARE NOT able to bring a laptop computer to the workshop.

Travel InformationPlease provide as much information about your travel plans as is known at this time. Travel Method:

I will be traveling by car.
I will be traveling by air.

Incoming Flight InformationAirport

Date

Airline

Flight Number

Time of Arrival

Outgoing Flight InformationAirport

Date

Airline

Flight Number

Time of Departure

Number of nights needed at the hotel:

Do you have a disability, food allergy, or preference that requires accommodation at the workshop? If so please describe:

Do you anticipate difficulty walking short distances to meals?

Yes
No

Workshop Product ReleaseIn confirming my registration for this workshop, I agree that any audio recording or images (still or video) made of me during the workshop may be used on the project website, in printed project publications, and in materials developed by the project. I further agree that my contributions to creative works that emerge from workshop activities (e.g., discussions on the listserv, contributions to the web page, summaries of group discussion, etc.) may be used by the workshop series, PIs, and conveners for development of future workshop materials, for scholarly reports, and for promotion of the workshop series. Attribution for original contributions will be made whenever possible.

Name Email *Please type the two distorted words into the box below. Separate them with a space. This helps us prevent spam. For more details or help click the question mark.

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