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Registration for SFAz Grand Challenges Conference April 12-13, 2010

 

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1. Enter your demographic information:

Enter your demographic information:   First name:
Last name:
Address:
Address 2:
City/Town:
State:	-- select state --AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming
ZIP:
Email Address:
Phone Number:
Cell Phone Number:

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2. Gender:

Gender:   Male Female

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3. Choose the category that best describes your role at this conference:

Choose the category that best describes your role at this conference:   SFAz fellow Industry Partner Faculty Advisor/Mentor Gov't Rep Community Partner Keynote Speaker Organizing Committee Volunteer

4. If you are NOT an SFAz Fellow, will you require accommodations at the Sheraton Hotel for Monday Night?

If you are NOT an SFAz Fellow, will you require accommodations at the Sheraton Hotel for Monday Night?   Yes No

If yes, please describe any special requests for these accommodations (i.e., single/double, special instructions, etc.)

5. If you are NOT an SFAz Fellow or Organizing Committee member, which sessions do you plan to attend? (Check all that apply)

If you are NOT an SFAz Fellow or Organizing Committee member, which sessions do you plan to attend? (Check all that apply)   Keynote: Dr. Murray (Monday afternoon) Poster Session I (Monday afternoon) Keynote: Drs. Hartwell & Nelson (Tuesday morning) Poster Session II & Closing Reception (Tuesday afternoon)

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6. Affiliation:

Affiliation:   Arizona State University Northern Arizona University University of Arizona Industry Partner Science Foundation Arizona Other

Other (please specify)

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7. Are you a U.S. Citizen?

Are you a U.S. Citizen?   Yes No

8. FELLOWS & FACULTY ONLY: What is your academic unit/program and concentration?

FELLOWS & FACULTY ONLY: What is your academic unit/program and concentration?

9. FELLOWS ONLY: Please indicate your beginning cohort year:

FELLOWS ONLY: Please indicate your beginning cohort year:   2007-08 2008-09 2009-10

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10. Dietary Restrictions and Preferences (check all that apply):

Dietary Restrictions and Preferences (check all that apply):   No restriction Vegan (no dairy/meat/fish/eggs) Vegetarian (no meat/fish) Gluten sensitivity Lactose Intolerant Kosher Other

Other dietary needs: (please specify)

11. Please indicate any special physical accommodations:

Please indicate any special physical accommodations:

12. FELLOWS ONLY:

	Size:
Please indicate your shirt size:	smallmediumlargeextra-large FELLOWS ONLY:   Please indicate your shirt size:   Size:

13. Indicate if you are willing to volunteer for any of the following:

Indicate if you are willing to volunteer for any of the following:   Car pool driver Assist with day-of registration Industry Visit Coordinator

14. FELLOWS ONLY: Do you have any attendance conflicts that will limit your participation on either day?

FELLOWS ONLY: Do you have any attendance conflicts that will limit your participation on either day?   Yes No