Workshop Registration

Contact InformationFirst Name:

Last Name:

Institution:

Department:

Address:

City:

Select a State:

Zip Code:

Phone:

FAX:

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.)

Question SetWhat is one thing you'd most like to gain from this workshop?

Please respond to one of the following two questions.

Please share one thing you do to support the success of all students and/or to broaden participation of underrepresented groups in the geosciences.

Describe one challenge that you face in supporting the success of all students and/or working to broaden participation of underrepresented groups in the geosciences.

DemographicsGender:

Male
Female
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

Race (select one or more):
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Disability status (select one or more):
Hearing Impairment
Visual Impairment
Mobility/Orthopedic Impairment
Other
None

Current position:

Discipline:

or Other discipline:

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.