Ohio Student Research Forum Faculty, Staff and Grad Student Registration

OHIO ALLIANCE FACULTY, STAFF, GRAD STUDENT
AND GRADUATE SCHOOL REGISTRATION FORM.
Areas marked with an asterisk (*) are required fields.

PART I - PERSONAL DATA
	Type your name as you would like it to appear on your name badge
First Name:*
Middle Name:
Last Name:*

Mailing Address:*

City:*
State:
Zip:*
Phone:	xxx-xxx-xxxx
Alt Phone (Cell):	xxx-xxx-xxxx
E-Mail:*
Alternate E-Mail:


Alliance Institution:
	Other Institution (if not listed above):
Title:
College/ Department:

Gender:*	Male Female

Race/Ethnicity:*	African American Asian American Pacific Islander Native American White Hispanic
	Other ( )

Citizenship:	US Citizen?	Ohio Resident?	Permanent Resident? (Green Card Holder)

PART II - SPECIAL NEEDS
Meal Preferences:	Vegan Vegetarian Other ( )

Disability/Accessibility:	What kind of amenities do you require? Please explain.


Parking:	Will you need parking on campus? Yes No
	If you arrive by carpool, mark yes only if you are the driver.

PART III - WORKSHOPS AND SMALL GROUP DISCUSSIONS
Yes No	Would you be interested in leading a workshop, serving on a panel, or moderating the session on oral presentations?

PART IV - LOGISTICAL ARRANGEMENTS
Ohio Science and Engineering Alliance faculty, staff, and graduate students are encouraged to participate fully in this Forum. Funds from the NSF grant will be used to cover their hotel rooms (for out of town visitors) and other Forum related expenses. In order for us to make the necessary reservations and to plan for the meals, please indicate below whether you will need a room for the night of August 7th and whether you will be present for each of the meals.

Yes No	Hotel room requested? (University Plaza, Thursday, August 7)
Yes No	Lunch (12:15 PM, University Plaza, Thursday, August 7)
Yes No	Dinner Banquet (6:30 PM. University Plaza, Thursday, August 7)
Yes No	Breakfast (7:00 AM, University Plaza, Friday, August 8)
Yes No	Lunch (12:15 PM, Ohio 4-H Center, Friday, August 8)

Updated 6.24.08