SERC > SERC Workshop Module Template > Registration Form - Standalone Option

Workshop Registration Form

Registration deadline: xxx,xx,20xx

Insert instructions here if the applicant must also register for the overarching conference such as GSA or AGU.

Complete the following form and click on SUBMIT to confirm your registration. Be sure to hit the SUBMIT button before leaving this page or your information will be lost. We encourage you to compose your answers to the longer questions in a word processor and to cut and paste the resulting text into this form.

Contact InformationFirst Name:
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Last Name:
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Department:
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Institution:
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Address:
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City:
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Select a State:

Zip Code:
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Phone:
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FAX:
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Email Address:
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Confirm Email Address:
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(Please Note: Your email address is what we use to track your application and 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.)

Question SetIn general, what do you consider to be the characteristics of a strong assignment/activity?
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Why are you interested in participating in this workshop? Check all that apply.
Teaching quandary. You hope to figure out a solution to a specific issue you came across in a course.
Research interest. This workshop aligns with your own academic interests.
Pedagogical interest. You have always wanted to teach students this content, set of skills or in this manner.
Colleague suggestion. A colleague recommended the workshop to you.
Community interest. You want to take part in an activity with like-minded colleagues outside of your institution (as well as learn something).
Career development. You want to prepare yourself for the next stage of your career.
Other:
If other, please specify:
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question 2
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question 3
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question 4
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DemographicsGender:

Male
Female

Ethnicity (choose one):

Hispanic or Latino
Not Hispanic or Latino

Race (select one or more):
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Disability status (select one or more):
Hearing Impairment
Visual Impairment
Mobility/Orthopedic Impairment
Other
None

Citizenship (choose one):

U.S. Citizen
Permanent Resident
Other non-U.S. Citizen

Number of years of full-time teaching experience:
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Number of years teaching at the college level:
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Current position:
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Discipline:

or Other discipline:
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Will you teach next fall at an institution that serves a large number of minority students?:

Yes
No

Which of the following best describes the department or program in which you will teach next fall:

Two year college (Associate is the highest degree)
Private four-year primarily undergraduate (BS or BA is the highest degree)
Public four-year primarily undergraduate (BS or BA is the highest degree)
Masters granting (MS is the highest degree)
Doctoral granting (PhD is the highest degree)

How did you learn about this workshop?

If there is other information relevant to your application, please let us know here:
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AccommodationsDo you have a disability, food allergy, or preference that requires accommodation at the workshop? If so please describe:
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Research ReleaseI 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 all aspects of this study, EXCEPT the following:

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 email list, 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.

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