Workshop Registration

Participant InfoFirst Name:

Last Name:

Institution

Campus, if applicable

Department

Email Address:

Please re-enter your email

(Please Note: We use your email address to track your application and participation in the workshop and to communicate with you. Be sure to use the same email address in all forms relating to your workshop participation.)

Which activity or activities are you registering for? September 25
October 2

Workshop QuestionsWhat do you hope to gain from participation in this workshop?

If you have developed a resource or activity or initiated a program that relates to the themes of the workshop, please describe it.

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

Position InformationWhich best describes your position?

Full-time permanent instructor
Full-time temporary instructor
Adjunct instructor at one institution
Adjunct instructor at multiple institutions
Non-instructional position
Grad student or post-doc

Other position:

How many years of college teaching experience have you had since graduate school?

0-3 years
3-10 years
More than 10 years

In what fields do you teach? Please check all that apply.
Astronomy
Atmospheric Science, including Meteorology
Biology
Chemsitry
Earth System Science
Environmental Policy/Studies
Environmental Science
Geography, Human
Geography, Physical
Geology
GIS
Mathematics
Oceanography
Physics
Other fields:

Demographics

The following information will be reported only in aggregate.

Gender:

Female
Male
I do not self-identify as either male or female
I prefer not to answer

Ethnicity (choose one):

Hispanic or Latino
Not Hispanic or Latino
I prefer not to answer

Race (select one or more, or leave all boxes blank if you prefer not to answer):
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Do you currently have a disability? This question is for demographic data collection; we will ask separately about whether you need accommodation at workshops.

No
Yes
I prefer not to answer

Are you a veteran or member of the armed forces?

No
Veteran
Currently serving in armed forces
I prefer not to answer

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.

I consent to participate in all aspects of this study EXCEPT those listed in the box below:

Workshop Product Release

In confirming my participation in this project, I agree that my contributions to creative works that emerge from project 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 other project products. Attribution for original contributions will be made whenever possible.

I further agree that any still images and audio/video recordings of my participation may be used on the project website, in printed project publications, and in materials developed by the project, EXCEPT as listed in the box below.

SAGE 2YC

Faculty as Agents of Change

Workshop Registration

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