SERC > SERC Workshop Module Template > Registration
Below you'll find an example of a workshop registration form. You'll want to work with SERC staff to develop an registration form appropriate for your workshop. You can download a .doc version (Microsoft Word 111kB Jul17 09) of this form to markup and use in communicating what you want for your form.

Confirmation deadline is ENTER DATE

For further information, contact INSERT COVENER EMAIL HERE
Please download the following medical and emergency information form, complete it, and bring it with you to the workshop in a sealed envelope. Medical Emergency Information Form

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. We'd 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.

Be sure to click SUBMIT when you are done. 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.
Participant Information













(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.)

Workshop Questions

Why are you interested in participating in this workshop? Check all that apply.













Travel InformationINSERT PARAGRAPH ABOUT TRAVEL LOGISTICS HERE.




Incoming Flight Information









Outgoing Flight Information











Diet and Mobility Accommodations





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.





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