Membership, Conference & Meeting Registration Form

Name Name * First Last
E Number *
Are you: *

Are you: Faculty Graduate Undergraduate Staff Guest
Do you receive a regularly scheduled paycheck from the university or are you currently serving as a student tutor? *

Do you receive a regularly scheduled paycheck from the university or are you currently serving as a student tutor? Yes No

Are you an employee? If so, a travel application is required prior to registration.
If you are a student or guest, indicate the faculty member who is sponsoring/mentoring you.
Your Email Address *
Date of Birth Date of Birth * / MM / DD YYYY

This is sometimes needed for conference registrations. It is always needed for flights.
Home/Campus Address Home/Campus Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home/Campus Phone Home/Campus Phone - ### - ### ####
This is for a: *

This is for a: Conference or Meeting Registration Membership/Dues Registration
From what account or ORG will this registration or membership be paid? *
Name of Conference *

If this is not conference travel, indicate NONE
Web Site for Conference Registration or Membership Dues
*
Date of Conference or Meeting Date of Conference or Meeting / MM / DD YYYY
Last date to register for conference at the lowest rate Last date to register for conference at the lowest rate / MM / DD YYYY
Are you a member of this organization? If so, what type? *
If not a member, and membership is required prior to registration, how will this be handled?
Are you expecting to receive a travel award or grant that may help pay for any portion of this trip? Please detail below. *

COS Undergraduate award, Williams Travel Award, etc.
Are you presenting? *

Are you presenting? Yes No
If yes, please attach a copy of your abstract acceptance letter here.
Title of Presentation

The name of your poster, presentation or purpose of travel.
Is there a login or ID needed for your conference or membership registration? If so, enter it here. *

If there's no login required, type "NONE"
Is there a password needed for your conference or membership registration? If so, enter it here. *

If there's no password required, type "NONE"
Name as you would like it to appear on conference badge.
Many meetings ask for a nickname. If they ask what should we use?

Many meetings ask for a nickname. If they ask what should we use? Example of a badge with nickname: Robert "Bud" Fisher
If they ask for a title, what should we use?

If they ask for a title, what should we use? Dr. Graduate Student Mr. Mrs. Ms. Other (type it in comments at bottom of form)
Meal Options

Meal Options I'm a meat eater! Vegetarian Vegan Gluten Free I have other food options or allergies that I will detail in the comments section at the bottom of the form
Comments and any further information

Use this area for any further information you need to share with the office regarding this registration.