Workshop Registration

Confirmation deadline is Friday, April 27, 2012

This registration form is for use only by applicants accepted to the workshop. If you have not been notified of your acceptance, do not complete this form. For further information, contact Krista Larsen.

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

You must complete this form in one sitting; you cannot save a portion and return to fill out the rest later. Also, remember that you will not be able to alter your registration information via this form once you have submitted it, so please be sure you have completed all fields before submitting.

Contact InformationFirst Name:

Last Name:

Name for Badge:

Your institution:

Your department:

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.)

If there is anyone you would like us to contact in the unlikely event of an emergency during the workshop, please enter their name and contact information here:

Accommodation Hotel Information Our grant will cover the cost of lodging on Wednesday, June 27th and Thursday, 28th for double occupancy rooms. Please see the list of participants to select a roommate.
If you prefer, you may request a private room. You will be responsible for paying for this option (approximately $130).

Double occupancy, no roommate preference.
Double occupancy, roommate preference (indicate below)
Single occupancy, I will pay $65 per night for this option now, using the payment page.

Visit the payment page to pay for the single occupancy option.

Roommate preference (name), if applicable

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

Do you anticipate difficulty walking moderate distances?

Yes
No

Optional Field Trip
There is an optional post-workshop field trip available to Yellowstone National Park. The trip will cost $200 for transportation, double-occupancy lodging, and meals on Saturday (Note: you may request single occupancy lodging for the field trip for an increased fee). For information on what the trips will entail, please visit the logistics page (opens in new window). Please indicate if you will be participating below. To register and pay for the field trip, visit the payment page (opens in new window).

Please select one:

I will attend the optional field trip to Yellowstone National Park (registration for field trip is made on the separate payment page)
I will NOT attend the optional trip

Research Release

I have read the Description of the Evaluation of Workshop Participation (opens in a new window) or it was read to me. I know the possible risks and benefits. I know that being in this study is voluntary. I choose to be in this study. I know that I can withdraw at any time. I am at least 18 years of age and voluntarily grant permission for the described release and use of notes and comments regarding me in the workshop.

Please select one of the following choices to indicate your level of desired participation in the study:

I consent to participate in ALL aspects of this study. My pre-workshop information, all workshop information, and follow-on workshop information can be used in this study, and I agree to participate in a follow-up interview in approximately 2-6 months which will be audio taped. Video, still images, and audio collected at the workshop may also be used in the research project.

I consent to participate in all aspects of this study EXCEPT those listed in the box below:

Workshop Product Release

In 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 InTeGrate 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 email list, contributions to the web page, summaries of group discussion, etc.) may be used for development of future workshop materials, for scholarly reports, and for promotion of the project. Attribution for original contributions will be made whenever possible.

I agree that I will attend the entire workshop.

I also accept responsibility to cover any costs incurred should I withdraw from participation in the workshop after I register. I understand that arrangements have been made on my behalf that have associated real costs (e.g. lodging, logistics, materials), and in many cases, my registration has secured a place that has been denied to other interested colleagues. Exceptions will only be made in cases of extreme personal hardship. 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.