Form 1 Cognitive Think Tank Registration Form

OMB No.: 0925-0740

Expiration Date: 5/31/2019

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0046). Do not return the completed form to this address.

Cognition and Medical Image Perception Think Tank Registration Form

1. First Name         

2. Last Name          

3. Degree (e.g., MD and PhD)

4. Title (e.g., Associate Professor)  

5. Organization      

6. Phone Number

7. Email 

8. Assistant’s Name              

9. Assistant’s Phone             

10. Assistant’s Email

Speakers, if you have not already emailed these to us, please upload the following:

11. Professional Headshot (Please upload a high-resolution headshot at least 960 x 720)

12. Brief bio (limit 250 words). Please cut and paste or type your bio into the space below.

13. I consent to be photographed while attending the Cognition and Medical Image Perception Think Tank event. I further authorize that the photographs may be published.

Yes No

14. Attending Scientific Networking Event (An optional happy hour/dinner after Meeting Day 1. Attendees will be responsible for their happy hour/dinner cost.)

Yes No

Attendees will be responsible for getting their own lunch at their own cost.

There is a cafeteria in the NCI building on the Terrace Level (this link provides more information about the food available in the cafeteria). In addition, there are a number of restaurants and cafés located near NCI Shady Grove.

15. You can pre-order a lunch for the first day of the meeting (Thursday, September 12) at a cost of $13. Payment must be made at the registration desk with exact cash only.

1. Will you purchase a boxed lunch for Day 1?

Yes No

2. Pre-ordered Lunch Choices (Will include freshly baked cookie and bag of potato chips):

Roast Beef with Cheddar on Focaccia roll

Baked Ham and Swiss on Focaccia roll

Turkey with American Cheese on Focaccia roll

Chicken Salad on Focaccia roll

Tuna Salad on Focaccia roll

Roasted Vegetables and Mozzarella Wrap

3. Enter Special Instructions Here:

4. Soft Drink Choices:

Bottled Water

Coke

Diet Coke

Lime Sparkling Water

V3 Evaluation 4/16/2019