Freshwater Future Fall 2011 Climate Symposium--Reg Deadline Oct 18

1. Copy of page: Registration

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1. Please provide the following contact information

Name: *

Organization:

Address 1: *

Address 2:

City/Town: *

State/Province: *

ZIP/Postal Code: *

Country: *

Email Address:

Phone Number: *

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2. Will anyone be joining you? If yes, please list their contact information below.

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3. In which Lake Basin do you reside?

Lake Superior

Lake Michigan

Lake Huron

Lake Erie

Lake Ontario

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4. How are you traveling to the Symposium?

I am flying.

I am driving.

I am taking a train.

Public Transportation

Other

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5. If you are flying, please tell us your airline, travel dates and times. If you are planning on applying for a scholarship, please call 231-348-8200 before making any flight plans.

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6. If you are driving, would you like to carpool? (highly recommended)

Yes

No, thanks.

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7. If you would like to carpool, where are you traveling from and when will you be traveling? (We will use this information to connect you to participants traveling from the same area.)

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8. Please list any dietary requirement.

Vegetarian

Vegan

Allergies (please specify below)

Other (please specify)

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9. Will you need a hotel room? (We will be staying at the County Clare Irish Pub and Guest House www.countyclare-inn.com)

Yes, Thursday night only

Yes, Friday night only

Yes, Saturday night

Yes, Thursday and Friday nights

Yes, Friday and Saturday night

Yes, three nights (Thurs, Fri, Sat)

No thanks

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10. If you need a hotel room, do you have a preferred roommate?

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11. Will you be applying for a travel scholarship to attend the Symposium?

Yes

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12. If applying for a travel scholarship, please list the following:

Number of miles driving

Airfare

Amount of travel assistance requested

Total Request

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13. 14. What type of work does your organization engage in?

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14. What climate adaptation work would you like to engage in?

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15. Do you plan to apply to Freshwater Future for a Climate Grant?

Yes

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16. If yes, we will send you materials to bring to the Climate Symposium that will help you to prepare a Climate Grant application.

There is a $25.00 registration fee. Scholarships are available. Please send a $25.00 check to:
Climate Symposium Registration
Freshwater Future
P.O. Box 2479
Petoskey, MI 49770