Registration deadline: xxx,xx,20xx

Insert instructions here if the applicant must also register for the overarching conference such as GSA or AGU.

Complete the following form and click on SUBMIT to confirm your registration. Be sure to hit the SUBMIT button before leaving this page or your information will be lost. We 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.

(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.)
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Please provide a headshot of yourself to be associated with your profile. If you already have a profile image (see right) you can skip this step (uploading a new image will replace an existing image).

You can edit the photo and your bio later by editing your SERC account page (opens in a new page) in the upper left hand box.

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

THIS SECTION MAY REQUIRE SIGNIFICANT EDITS. Consult with the evaluation team or the project evaluator.

The following information will be reported only in aggregate. We collect these data for our reports to the National Science Foundation, which funds this project. You are welcome to skip any of these questions if you prefer not to answer them.

Race (select one or more, or leave all boxes blank if you prefer not to answer):

Everything below this point is just examples of what other project have choosen to collect. You should not use these questions unless it's clear a project has a defined need for the data.

THIS SECTION MAY REQUIRE SIGNIFICANT EDITS. Consult with the evaluation team or the project evaluator.

Information for this research study is collected via a mixed-method approach that includes artifact analysis, baseline programmatic inventory, surveys, personal interviews and focus groups, structured classroom observations, faculty reflections, network analysis, and site visits to each Change Agent Team over the duration of the program. These data will be incorporated into our research results in aggregate. Presentation of the material will be confined to project work groups, professional publications, and conferences. When individual quotes are used to illustrate important points, your name will not be identified. There are no foreseeable risks resulting from your participation. Your participation in this research project is voluntary and you may leave at any time.

I have read the Description of the Research Project and Implications for Participation (opens in new page) 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.

* required

We believe that showcasing the individuals who make [THIS PROJECT] a success engaged in the work together is a critical part of increasing the reach and impact of the project. To that end, we will be taking photographs of participants in action during the [EVENT]. We use photos like these to enhance the quality of our website and print publications as well as project documentation for NSF and the [PROJECT] community.

As a participant, you have the right to opt out of having your photograph taken by project staff at the event. We'll make our best effort to avoid capturing your image in photos we take at the event. If we inadvertently capture your image in a photo that gets posted on the website, please let us know so that we can remove it promptly.

Note, this opt out does not apply to photos that might be taken and used by others who attend the workshop. Individuals who have opted out should endeavor to alert photographers should they see someone in their vicinity taking pictures, so that they are not accidentally captured in crowd shots.

* required

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 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.