Cognitive Think Tank Registration Form

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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. 
        a. Will you purchase a boxed lunch for Day 1? 
	Yes 		No 
        b. 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
        c. Enter Special Instructions Here:
        d. Soft Drink Choices: 
Bottled Water
Coke
Diet Coke
Lime Sparkling Water