Registration for 2017 Undergraduate Research Symposium in the Biological Sciences and Psychology at Washington University in St. Louis, November 10-11, 2017
This is the registration form for the Midstates Consortium 2017 Undergraduate Research Symposium in the Biological Sciences and Psychology at Washington University in St. Louis, November 10-11, 2017.

The registration deadline is Friday, September 29, 2017. It is important that EVERYONE presenting register. Listing the people you are presenting with DOES NOT automatically register them. Faculty members also need to register using the same form -- just leave blank any irrelevant fields.

If you instead want to register for the Undergraduate Research Symposium in the Physical Sciences, Math, and Computer Science at the University of Chicago, November 3-4, 2017, please go to http://tinyurl.com/ybwrvj4j

College or University you attend or work at
First name
Your answer
Last name
Your answer
Name you would like on your nametag (first and last)
Your answer
Email
Your answer
Cell phone number (in case we need to contact you while traveling)
Your answer
Preferred phone number for us to call when you are not traveling (leave blank if same as above)
Your answer
Status (first-year, sophomore, junior, senior, graduate student, faculty)
Gender (for room sharing purposes)
Rooming preferences (preferred roommates and special requests)
We house students 4 to a room and faculty members 2 to a room. Rooms are single sex. List names if you have specific people you'd like to room with. If you have any other special rooming requests, please list them here.
Your answer
Presentation preference (oral or poster or not applicable)
Presentation title (15 word max)
15 words, no special characters except Greek letters and punctuation. First word and proper noun capitalization only.
Your answer
Abstract
200 words. No figures, tables, or references. Avoid special characters other than Greek letters if possible - please put a note if a special character is required.
Your answer
Co-presenter names (if any)
Full first (given) name followed by last (family) name. Middle names/initials optional. No titles (Dr., Prof.), no degrees (Ph.D., M.D.). Other suffixes OK (III, Jr.)
Your answer
Co-author name(s)
Full first (given) name followed by last (family) name. Middle names/initials optional. No titles (Dr., Prof.), no degrees (Ph.D., M.D.). Other suffixes OK (III, Jr.)
Your answer
Research adviser's name
Full first (given) name followed by last (family) name. Middle names/initials optional. No titles (Dr., Prof.), no degrees (Ph.D., M.D.). Other suffixes OK (III, Jr.)
Your answer
Research adviser's department
Your answer
Research adviser's college or university
Your answer
Research adviser's email
Your answer
Emergency contact info (name(s) and phone number(s))
Your answer
Dietary restrictions
Food allergies? (please list)
Your answer
Please include any other special needs or requests (wheelchair access, health concerns, food allergies, etc.)
Your answer
Permission to use pictures
Do you give MCMS permission to use pictures from Consortium events that include me on the MCMS website and other Consortium related materials?
Midstates Consortium Undergraduate Research Symposium Release
Participant's Statement of Responsibility, Release from Liability and Agreement to Indemnify. I have registered for the Undergraduate Research Symposium sponsored by the Midstates Consortium for Math & Science. In exchange for permission to participate, I have read and understand, and agree to comply with the following Statement. 1). My participation in the Midstates Consortium Undergraduate Research Symposium is entirely voluntary, and has been undertaken at my request and for my benefit. The symposium requires travel away from my institution and I will be staying away from home and/or school overnight. These activities can carry some risk of injury to person or property. I recognize that any travel can carry some risk and I assume all responsibility for the risks presented. 2). I hereby waive and release any chaperone, faculty member, officer, agent, or employee of the Midstates Consortium, from liability to the participant, my personal representatives, their assigns or heirs, for all loss or damage, on account of injury to property or to the person (even if resulting in death) where such loss or damage was caused by, arose out of, or was in any way related to the symposium and its related travel. This release applies to all actions or failures to act by which it is claimed a loss or damage was caused. 3). This release shall apply without limitation to any loss or damage which occurs while en route or returning from travel. It shall apply to all injuries caused by or resulting from travel or travel conveyances; places of lodging including hotels/motels and the host residence; to the ingestion of food or drink; engaging in any activities whether authorized or unauthorized by the chaperones: the authorization of medical treatment and actions or inactions made in response to emergencies occurring during any of the foregoing activities. 4). The Midstates Consortium and the participant's institution have the authority to establish rules necessary for the operation of the program. Should the faculty sponsor decide that a student must be separated from the program because of violation of any rule, or disruptive behavior, or for conduct which could bring the symposium into disrepute, that decision will be final. I understand that this document contains a release of liability. I represent to the Midstates Consortium that: I have read this statement carefully and thoroughly; I understand and agree to all of the terms of this statement; and I have executed this statement voluntarily.
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