Workshop Registration Form

Confirmation deadline is 5 July 2017

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.

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 InformationFirst Name:

Last Name:

Name of Institution:

Department:

Name for Badge:

Email Address:

Confirm Email Address:

(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.)

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.)

(Optional) Please list the person you would like us to contact in the unlikely event of an emergency during the workshop and their contact info.

Diet and Mobility Accommodations I prefer vegetarian options

Please describe any other food allergies, preferences, or dietary restrictions that require accommodation at the workshop:

Do you anticipate difficulty walking moderate distances?

yes
no

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 or online 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 conveners in future workshops/conferences, and for the development of educational materials and scholarly reports. Attribution for original contributions will be made whenever possible.

Name Email