UCSF/UCB Graduate Group in Bioengineering
Fall 2008 Group Conference

Registration
October 24-26, 2008

You should complete this form only once.
If you complete this form more than once you must re-enter all information.

* fields are required

Last Name:*
 First Name:*
Student/Alumnus/Faculty/Staff (please select one): *
Student
  year entered program
Alumnus
  graduate year
Faculty
 
Title:
   Department:
Staff
Gender: *
Female
Male
Meal Preference:*
Regular Meals
Vegetarian Meals
T-shirt Size:
Small
Medium
Large
XLarge
E-Mail: * Phone:*    
xxx-xxx-xxxx
Campus Address: * Campus Box:
City: * State: *
Zip: *  
Primary Registration Preferences :
* Select one, A, B, or C.
A. Attending the entire conference Friday through Sunday.
(Including shared lodging both nights, all meals.) Registration fee $300 per person if registered by July 24, or $400 thereafter.
B. No Lodging required but attending the conference.
Off Grounds Attendee, includes entire conference and all meals (no lodging). Off Grounds fee $250 per person if registered by July 24, $300 thereafter.
C. Partial Attendance.
Check below all attendance requests including shared lodging and meals. Registration fee $300 per person if registered by July 24, or $400 thereafter.

Friday, October 24:
Friday Conference Lodging Friday Night Friday Dinner

Saturday, October 25:
Saturday Conference    Lodging Saturday Night Saturday Dinner

Sunday, October 26:
Sunday Conference Sunday Breakfast Sunday Box Lunch

Special needs or accommodations required, please list.

I request a private room, and agree to pay an additional $100
($400 before August 29, $500 thereafter)
Transportation:

Will you be taking the group van?
Yes
No

If no, and you are driving yourself, would you like to carpool?
Yes
No

Thank you, you will be contacted about tranportation by the organizers.

Will you volunteer to volunteer to drive a 12-passenger rental van? (Must be 21 years of age)
Yes
No

If so, would you prefer to drive a rental van from the UC San Francisco area or the UC Berkeley area?
Mentors:
Per the Mentor/Lab Committment, mentors are to pay for mentored students. Please enter mentored student names here. The registration fee for mentored students is $300.00 per person if registered by July 24, or $400.00 thereafter.
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Guest Registration:
Guest fee is $250 per guest if paid by July 24, and $300 thereafter, includes shared lodging and meals (not attending the conference).
Guest 1 Last Name:

Guest 1 First Name::
Guest 1 Meal Preference:
Regular Meals
Vegetarian Meals
Guest 2 Last Name::

Guest 2 First Name:
Guest 2 Meal Preference:
Regular Meals
Vegetarian Meals
Child 1 Last Name:
 Child 1 First Name:
Child 1 Age:
Child 1 Meal Preference:
Regular Meals
Vegetarian Meals
Child 2 Last Name::

Child 2 First Name::
Child 2 Age:
Child 2 Meal Preference:
Regular Meals
Vegetarian Meals

Payment Method

Select payment method below. Early registration will be appreciated. Fees increase after July 24. Register now and save!

Students: Faculty Mentor (name):
Mentors are responsible for the registration fees of the graduate bioengineering students in their labs (as stated in the Group's Mentor Financial Support Requirements).

Choose a payment method:
    Select one *

UCSF: I will request a journal transfer from my mentor's financial assistant to Bioengineering: DPA & Fund 404910-69712
Berkeley: Charge UCB Chartstring/Account. Fund # or Mentor Name
    For either of the above:
Name of mentor's financial assistant:
Contact # or email address:
Amount Paid with UCB or UCSF Account: $
Student Fee Waiver Requests: Incoming and current students without a mentor or extramural travel funds will be confirmed by administration.
Payment by Check
Personal Check (Make checks payable to UC Regents. Mail checks to Department of Bioengineering, 306 Stanley Hall #1762, Berkeley, CA 94720-1762 in care of Rebecca Pauling.)
    Check Amount $
   
Check to be used for payment of the following (please check all that apply):
This Registrant
Mentored Students
Guest(s)
Donation

Contact Rebecca Pauling (510) 642-9931 for additional information.


Donation
Additional donation for the Group's Donor Fund are welcome.
Make checks payable to UC Regents. Mail to Bioengineering Graduate Group c/o Department of Bioengineering, 306 Stanley Hall #1762, Berkeley, CA 94720-1762 in care of Rebecca Pauling.
Amount $