Neuroscience Retreat Registration Form

Registration deadline is: Friday, May 11th, 2018 at 11:59PM.

First Name:   Last Name:  
E-mail:
Phone:
Position:
  
While invited speakers and first-year students are exempted,
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 Monday, June 18th?:     Yes  No 
Lunch on Monday, June 18th?     Yes  No 
Dinner on Monday, June 18th?     Yes  No 
  
Will you be staying overnight
on Monday, June 18th?
     Yes  No 
Preferred Roommate:
  
Will you be present for Tuesday, June 19th?:     Yes  No 
Lunch on Tuesday, June 19th?     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.