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2018 Systemic Change Institute Registration
Confirmation deadline is
Friday, June 22nd
For further information, contact the ASCN Hub, cricpe-ascn 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 Information
First 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.)
Accommodations
Dietary Accommodations
I prefer vegetarian options
Please describe any other food allergies, preferences, or dietary restrictions that require accommodation at the workshop:
Mobility Accommodations
This hotel has ADA accessible rooms available. If you have additional needs related to accessibility, please indicate so here. Do you need any mobility accommodations?
yes
no
If yes, please describe:
How would you prefer to receive the documents for this event?
Hard Copy Binder
Electronic Version
Demographics
Gender:
Male
Female
Transgender
I prefer not to respond
Preferred pronouns: (e.g.
she/her/hers
)
Ethnicity (choose one):
Hispanic or Latino
Not Hispanic or Latino
I prefer not to respond
Race (select one or more):
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
I prefer not to respond
Disability status (select one or more):
Hearing Impairment
Visual Impairment
Mobility/Orthopedic Impairment
Other
None
I prefer not to respond
Workshop Product Release
In 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.
Payment
In order to pay your fees for the leadership institute, please go to the University of Texas at Austin payment center (opens in new window):
Teams with
four
attendees go here
Teams with
five
attendees go here
I also accept responsibility to cover any costs incurred should I withdraw from participation in the workshop after
June 22, 2018
. 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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