Online Registration Form

Name *

Full name of participant.

Email *

Email address of participant

Phone *

Phone number of participant.

Address *

Address of participant

City *

City of participant.

State/Province/Region *

Two-letter state/province/region of participant.

Zip/Postal Code *

Zip/Postal Code of participant

Country *

Two-letter country code of participant.

Participant type *

Regular - $400

Student/Postdoctorate - $200

Regular participant or student/postdoctorate?

Bringing a companion? *

Yes ($180)

You may bring a companion for an extra $180 (extra housing charges also apply).

Housing reservations *

Hotel reservations

Campus housing

Select either Hotel accommodations or Campus housing.

Room type *

Single - $65 a night

Double (two beds, private bath) - $50 a night

Double (two beds, shared bath with one other room) - $40 a night

Select the desired campus housing room type. (Note: must select a Double if bringing a companion.)

Room type *

Double (two beds, private bath) - $50 a night

Double (two beds, shared bath with one other room) - $40 a night

Select the desired campus housing room type.

Arrival date *

Year

Month

Day

Enter the date of arrival for campus housing purposes.

Departure date *

Year

Month

Day

Enter the date of departure for campus housing purposes.

Assign Roommate? *

Yes, automatically assign me a roommate

No, I already have a roommate in mind

Select 'Yes' if you would like a roommate automatically assigned. If you select 'No', you will need to provide the name of your roommate.

Roommate name *

Enter the name of your roommate.

Roommate Gender *

Male

Female

Please select your gender for roommate assignment purposes.

Institution

Please indicate which institution you belong to.

Name on badge

Please enter exactly the name you want on your badge.

Liability Agreement for use of the Buchanan-Kiewit Wellness Center

Complimentary access will be provided for participants living in campus residential housing while attending the Program.

I understand that by participating in the Program, I will have access to the Buchanan-Kiewit Wellness Center and may engage in: strenuous physical activity with or without other participants, competition, and other recreational activities. I acknowledge that these activities present certain inherent risks that are beyond Lawrence University’s control.

I choose to participate in the Program understanding its associated risks, and knowingly and voluntarily assume all risks of collision, injury, illness, death or damage to or loss of my property that may occur while engaging in activities Buchanan-Kiewit Wellness Center. I understand that I may discontinue participation at any time in light of the risks.

I hereby forever release Lawrence University, its trustees, officers, employees, and agents (the “Released Parties”), from liability for any negligent act or omission arising from my participation in the Program, including related costs, damages, claims or assertions to which I or my family, estate, or heirs may claim against the Released Parties.

This Assumption of Risk and Release of Liability shall be construed in accordance with the laws of the State of Wisconsin, which shall be the forum for any lawsuits filed under or incident to this Release or the Program.

Waiver of liability *

I have read, understand, and agree to the above

Liability Agreement

Sections

Workshop on Non-Neutral Plasmas