Registration

Below you'll find an example of a workshop registration form. You'll want to work with SERC staff to develop an registration form appropriate for your workshop. You can download a .doc version (Microsoft Word 111kB Jul17 09) of this form to markup and use in communicating what you want for your form.

Confirmation deadline is ENTER DATE

For further information, contact INSERT CONVENER EMAIL HERE

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. We'd 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.

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):

Photo Upload

Go to http://serc.carleton.edu/person/0.html

Your current profile image

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.

Profile photo upload

All uploaded files are public unless you are in a private workspace

Title: A descriptive, human readable title.

e.g. 'Student Handout for Sauerkraut Assignment'

Select the file: Make sure it has an appropriate suffix (e.g. .doc) or specify the type in the Optional Fields below

Description: A very brief description of the file.

Show Optional Fields

File Type:

The system will attempt to determine the correct file type based on the name of the file you've selected. Choosing the correct file type here will override that.

File Name:

e.g. 'student_handout'
This will be the name of the downloaded file. By default the system will generate this based on the title you specified and the type of file. If you specify a name here it will over-ride the automatically generated name. This is generally only useful when uploading file of a type not recognized by the system (not in the list of file types above). In that situation choose File Type: Unknown Binary and include the appropriate suffix in the file name here. e.g. myfile.m3z Avoid spaces or special characters in the file names.

Authorship/Reuse

Either:
I am the author (copyright holder) of the contents of this file and people are allowed to reuse it for non-commercial purposes as long as they give me attribution as described by this creative commons license.
Or

Choose a different authorship/reuse options

Who is the original creator/copyright holder of the information in this file?

Provenance/Acknowledgements

A short description of where the material came from. Include names and institutions of authors and contributors as well as acknowledgment of any work from which this was derived.

Reuse License

The creator/copyright holder must have agreed to allow distribution of this file through this site.
If you are the creator we strongly encourage you to select the CC Attribution-NonCommercial-ShareAlike option.

If none of the above licenses apply describe the conditions under which this material appears on this site as well as any information about reuse beyond this site.

More Information about reuse and choosing a license

Distributing information on the web generally requires the permission of the copyright holder--usually the original creator. Providing the information we request here will help visitors to this site understand the ways in which they may (legally) use what they find.

If you created this file (and haven't signed away your copyright) then we'd encourage you to select the CC Attribution-NonCommercial-ShareAlike option. You'll retain the copyright to your file and can do as you please with it in the future. Through this choice you are also explicitly allowing others to reuse that file as long as they give you attribution, and don't use it for commercial purposes.

If the file (or content within it) was created by others you'll need their permission. If it predates 1923 or was created by a U.S federal employee (as part of their job) it is likely in the public domain (and we can all do as we choose with it). The original author may also have explicitly stated how it may be reused (e.g. through a creative commons license). You can describe the licensing/reuse situation in the box above.

Without permission you should not upload the file. There are several options in this case:

You can contact the original author to get permission.
You can provide a link to (or a description of how to get) the original material rather than uploading it here.
You can find a substitute that isn't encumbered by copyright.
You can create a substitute yourself. Remember, ideas can't be copyrighted, only particular expressions of those ideas. Of course you'll want to give credit the original author.

The Stanford Copyright and Fair Use Center has more good information about copyright as it applies to academic settings.

Workshop QuestionsIn general, what do you consider to be the characteristics of a strong assignment/activity?

Why are you interested in participating in this workshop? Check all that apply.
Teaching quandary. You hope to figure out a solution to a specific issue you came across in a course.
Research interest. This workshop aligns with your own academic interests.
Pedagogical interest. You have always wanted to teach students this content, set of skills or in this manner.
Colleague suggestion. A colleague recommended the workshop to you.
Community interest. You want to take part in an activity with like-minded colleagues outside of your institution (as well as learn something).
Career development. You want to prepare yourself for the next stage of your career.
Other:
If other, please specify:

Question 3

Question 4

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

Research Release

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.

Please select one of the following choices to indicate your level of desired participation in the study:
* required

Full: I consent to participate in ALL aspects of this study. My comments (spoken or written) can be used to inform the study.
None: I would not like my comments to be included in the research
Partial: I consent to participate in all aspects of this study EXCEPT those listed in the box below:

Image Release

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.

I agree that still photos may be used on the project website, in printed project publications, and in materials developed by the project: * required

Yes
No

Workshop Product ReleaseIn 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.
Name Email

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