Workshop2013:registrationform

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Registration form

If you have already send this form, please do not send it again!

In order to amend you application or with other queries please email gaiasciencealertsworkshop2013@gmail.com


{{#form: action=http://www.ast.cam.ac.uk/~wyrzykow/cgi-bin/mailer.cgi | method=post}}

Contact details

Title (Mr/Mrs/Dr/Prof): name=dr|cols=5|style=width:auto|rows=1}}
Name: name=name}}
Affiliation: name=affiliation|cols=50|style=width:auto|rows=1}}
Work address: name=address|rows=3|cols=30|style=width:auto}}
Telephone: name=tel|value=don't forget your country code|cols=30|style=width:auto|rows=1}}
Email: name=email|rows=1|cols=20|style=width:auto}}

{{#input:type=hidden|name=wabik}}

Please give a short description of your current research and research interests, as well as a description of how you will contribute to and benefit from the workshop (<400 words) {{#input:type=textarea|name=research|rows=6|cols=100|style=width:auto}}


My contribution to the Workshop: name=contribution|
  • Please select
  • talk
  • none}}
Title: name=title|rows=1|cols=100|style=width:auto}}
Brief abstract: name=abstract|rows=4|cols=100|style=width:auto}}

Social Dinner

We plan to have a workshop's dinner on Thursday 20th

I would like to participate in the dinner: name=dinner|
  • Please select
  • yes
  • no}}

Other

Special dietary requirements (e.g. vegetarian, vegan): name=diet|value=No special dietary requirements}}
Disabled access: name=disabled|value=No special disabled requirements}}

Funding

Should you request any funding support, please email us directly with a justification and an estimate of the travel and accommodation costs. The support is available primarily for students and postdocs.



Now, make sure everything you entered is ok. If form is processed successfully you will receive a confirmation email.


{{#input:type=submit|value=Send}}

{{#formend:}}