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Freshwater Future Fall 2011 Climate Symposium--Reg Deadline Oct 18
6.
Copy of page: Registration
1.
Please provide the following contact information
(Required.)
Name:
*
Organization:
Address 1:
*
Address 2:
City/Town:
*
State/Province:
*
ZIP/Postal Code:
*
Country:
*
Email Address:
Phone Number:
*
2.
Will anyone be joining you? If yes, please list their contact information below.
3.
In which Lake Basin do you reside?
Lake Superior
Lake Michigan
Lake Huron
Lake Erie
Lake Ontario
4.
How are you traveling to the Symposium?
I am flying.
I am driving.
I am taking a train.
Public Transportation
Other
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.
6.
If you are driving, would you like to carpool? (highly recommended)
Yes
No, thanks.
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.)
8.
Please list any dietary requirement.
Vegetarian
Vegan
Allergies (please specify below)
Other (please specify)
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
10.
If you need a hotel room, do you have a preferred roommate?
11.
Will you be applying for a travel scholarship to attend the Symposium?
(Required.)
Yes
No
12.
If applying for a travel scholarship, please list the following:
Number of miles driving
Airfare
Amount of travel assistance requested
Total Request
13.
14. What type of work does your organization engage in?
14.
What climate adaptation work would you like to engage in?
15.
Do you plan to apply to Freshwater Future for a Climate Grant?
Yes
No
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
