2008 PCUMC Registration Form

1. Please provide the following contact information:

   Name
   Organization
   Street Address
   Address (cont.)
   City
   State/Province
   Zip/Postal Code
   Country
   Work Phone
   E-mail

2. Choose one of the following options:

   Freshman Sophomore Junior Senior Faculty Other
   

3. If you are a student, are you applying to give a student talk?

   Yes No
   

4. If yes, will you be jointly presenting with another student?

   Yes No
   

5. Please enter the names of joint presenters:

   
   

6. Please enter your title in the space provided below.

   
   

7. Please enter your abstract.

8. If you are applying to give a talk, do you prefer to give a 15 or 20 minute talk?

   15 minutes 20 minutes N/A

9. If you are applying to give a talk, choose a T-shirt size: S M L XL
10. Would you like a vegetarian option for lunch?

    Yes No

11. The following questions will help us with reporting to our funding sources. We appreciate your willingness to answer them.

    1. How would you identify yourself? African American Asian Caucasian Hispanic Native American Other

    2. What is your gender? Female Male

12. Are you a student requesting travel support? Yes No

If you answered yes to #12, please provide the following by Friday, March 14, 2008:

1. An estimated budget of your travel expenses, including airfare, ground transportation, lodging, and support from your home institution.
2. A letter from your academic advisor or department chair explaining that your institution cannot cover all of your travel expenses.

The items can be provided by email to ncameron at lclark dot edu OR by US mail to Dr. Naiomi Cameron at:

Department of Mathematical Sciences
Lewis & Clark College
MSC 110
0615 SW Palatine Hill Road
Portland, OR 97219