Registration

Confirmation deadline is July 15th

For further information, contact Inese Berzina-Pitcher, inese.bpitcher AT wmich.edu
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.

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 institute.)

Diet and Mobility Accommodations I prefer vegetarian options

Please describe any other food allergies, preferences, or dietary restrictions that require accommodation at the workshop:

This hotel is a new property and is fully accessible and completely ADA compliant. There are ramps and elevators available to access the various areas of the hotel, as well as a lift for the pool. If you have additional needs related to accessibility, please indicate so here. Do you need any mobility accommodations?

yes
no

If yes, please describe:

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 discussions, 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.

PaymentIn order to pay your fees for the leadership institute, please go to the University of Texas at Austin payment center (opens in new window).
Payment
Please select the appropriate option for your team.

I also accept responsibility to cover any costs incurred should I withdraw from participation in the workshop after July 15, 2017. 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

Leadership Institute Registration

Confirmation deadline is July 15th