TEST Registration Form from Salesforce Attendee InformationThis is how your name will appear on your name badge.Name* First Last Title/Position Kavli Institute Affiliation (pick one)Kavli Institute for Brain Science at Columbia UniversityKavli Institute for Brain and Mind at UCSD/SalkKavli Institute for Neuroscience at Yale UniversityKavli Institute for Systems Neuroscience at the Norwegian University of Science and TechnologyKavli Neuroscience Discovery Institute at Johns Hopkins UniversityKavli Neural Systems Institute at The Rockefeller UniversityKavli Institute for Fundamental Neuroscience at the University of California, San FranciscoThe Kavli FoundationEmail* Please include a short bio (<1000 characters including spaces)…… and a headshot to accompany your bio.Max. file size: 4 MB.The headshot and bio may be submitted at a later date.Gender (optional)FemaleMaleNon-binary, genderqueer, and/or gender fluidPrefer not to answerPlease list any dietary restrictions below. Type "none" if you have none.* Please request any disability accommodations below. ChildcareWe are looking into potential childcare options for the Forum. One potential option would be to provide childcare in New Haven. Another potential option would be funding to help pay for childcare-related costs necessary for you to attend this event. In order to help us research potential options, please answer the following questions:Will you need childcare support? Yes No If yes, would you prefer on-site childcare or a voucher/funding to use at your discretion? on-site funding/voucher Please list the ages of the children you will need childcare for, and any other information you think would be useful for us to know.LogisticsWill you be attending the Welcome Dinner on April 19th?* Yes No Will you be needing hotel accommodations in our room block?* Yes No We can accommodate extra nights for those traveling from outside the northeastern United States.Requested Check-in Date* MM slash DD slash YYYY Requested Check-out Date* MM slash DD slash YYYY Please describe any special needs you may have for accommodations.Scientific AbstractNote: The organizing committee will notify you early next year if you have been selected for a poster or a talk. Would you prefer to give a talk or a poster? Talk Poster No preference Note: we are planning to have senior faculty members participate as session moderators and/or give posters!Abstract Title Abstract (< 200 words)Which branches of neuroscience best describe your area of research? Behavioral Neuroscience Developmental Neuroscience Cellular and Molecular Neuroscience Systems Neuroscience Computational Neuroscience and Theory Neuroengineering You may select more than one category, or add your own below.What branch of neuroscience, not found above, best describes your area of research? Would you like to be part of the organizing committee? No Yes We would like to get diverse representation from all 7 Kavli Institutes in Neuroscience and will be notifying you in mid-December if you have been selected.
