Cognitive Think Tank Registration Form

Cognitive Think Tank Registration Form.docx

Conference, Meeting, Workshop, and Poster Session Registration Generic Clearance (OD)

Cognitive Think Tank Registration Form

OMB: 0925-0740

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OMB No.: 0925-0740

Expiration Date: 07/31/2022


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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:

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

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

  3. 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

  1. 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.

  1. 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

    1. 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

    1. Enter Special Instructions Here:

    2. Soft Drink Choices:

Bottled Water

Coke

Diet Coke

Lime Sparkling Water

V3 Evaluation 7/30/2019

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorGallicchio, Lisa (NIH/NCI) [E]
File Modified0000-00-00
File Created2022-02-14

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