Workshop Registration

Confirmation deadline is April 1, 2009

For further information, contact Len Vacher

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

First Name:
.
Last Name
.
Name of Institution:
.
Name for Badge:
.
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.)
.

Travel Information

Please schedule your arrival so that you can attend the Opening Reception and Dinner beginning at 5:00 PM. UW Bothell is located approximately 15 miles northeast of downtown Seattle.

Travel Method:
I will be traveling by car.

I will be traveling by air.

I will be traveling by train.

Incoming Flight InformationAirport
.
Date
.
Airline
.
Flight Number
.
Time of Arrival
.

Outgoing Flight InformationAirport
.
Date
.
Airline
.
Flight Number
.
Time of Departure
.

I am interested in sharing ground transportation to the workshop.
I will be renting a car (at my own expense).

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

Do you anticipate difficulty walking moderate distances on campus?
Yes

No

Research Release

I have read the Description of the Research Project and Implications for 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 some, but not all, aspects of this study. Please discuss with us the aspects in which you do NOT consent to participate.

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 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.

*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.

« Previous Page Next Page »