Neuroscience Retreat Registration Form

Registration deadline is: Wed. Apr. 19th, 2017, 11:59 AM.

First Name:   Last Name:  
E-mail:
Phone:
Position:
  
A fee of $100 per person will be charged to the lab PI's grant.
Requests for exemptions will be considered on a case-by-case basis
and should be made by email to Kamran Khodakhah.
Investigator:   Grant Number:  
  
You are encouraged to attend both days of the retreat. However, we are required to pay per person, per day.
Please indicate the following:
  
Will you be present for Wednesday, May 10th?:     Yes  No 
Lunch on Wednesday, May 10th?     Yes  No 
Dinner on Wednesday, May 10th?     Yes  No 
  
Will you be staying overnight
on Wednesday, May 10th?
     Yes  No 
Preferred Roommate:
  
Will you be present for Thursday, May 11th?:     Yes  No 
Lunch on Thursday, May 11th?     Yes  No 
  
Do you have strict dietary requirements (e.g. kosher, etc.)?     Yes  No 
  
Confirmation Code:

Please type the 5-character code on
the left into the above box
  
 Please review all of your answers before pressing the "Submit" button. Press the button only once.
If this is done properly, the confirmation page will be displayed.