Workshop Registration

Contact InformationFirst Name:

Last Name:

Institution:

Campus - If your institution has multiple campuses, please list your primary location

Department:

Address:

City:

Select a State:

Zip Code:

Phone:

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.)

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

How will you share what you learn at the workshop with your colleagues?

Position Information
Which 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

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
Earth System Science
Environmental Policy/Studies
Environmental Science
Geography, Human
Geography, Physical
Geology
GIS
Oceanography
Other fields:

DemographicsGender:

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):
Native Hawaiian or Other Pacific Islander
Asian
Black or African American
American Indian or Alaska Native
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

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

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.

SAGE 2YC

Faculty as Agents of Change

Workshop Registration