Registration

Participant InformationFirst Name:

Last Name:

Name of Institution:

Email Address:

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 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.

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. Video, still images, and audio collected as part of workshop activities may also be used in the research project.
I consent to participate in all aspects of this study EXCEPT those listed in the box below:

Product Release

In confirming my registration for this series of virtual professional development activities, I agree that my contributions to creative works that emerge from activities (e.g., discussions on the email list, contributions to the website, summaries of group discussions, etc.) may be used by the SAGE 2YC project and PIs for development of future workshop materials, for scholarly reports, and for promotion of the project. Attribution for original contributions will be made whenever possible.

SAGE 2YC

Faculty as Agents of Change

Registration

Please complete this registration form by April 16, 2018.