Workshop Registration

Geoscience and the 21st Century Workforce

Please use this form to confirm your attendance at the workshop. Note that this indicates your commitment that you will attend the workshop. Please complete this form by April 5, 2013.

Complete this form and click on the SUBMIT button at the bottom of the page to send us your registration information.

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. Please contact Karin Kirk with any questions. (kkirk [at] carleton [dot] edu)

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 address 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:

Hotel InformationThe InTeGrate grant will cover the cost of lodging on Wednesday, June 26 and Thursday, June 27 for double occupancy rooms.
If you prefer, you may request a private room. You will be responsible for paying for this option ($60 per night).

Double occupancy, no roommate preference.
Double occupancy, roommate preference (indicate below)
Single occupancy, I will pay $60 per night for this option now, using the payment page.

If you prefer to be paired with a specific roommate, please see the participant list (opens in a new window) and coordinate that with your preferred roommate and indicate your roommate preference here. We need both roommates to list each other on their registration forms so that we can be assured this is a mutual decision.

Visit the payment page (opens in a new window) to pay for the single occupancy option.

AccommodationDo 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

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.

By submitting my registration form, 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

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