SEEDS Participant Information Sheet

Contact Information

ATTENTION: The contact information you provide below will be used by the SEEDS program to relay important trip information and travel arrangements. Please provide accurate information for points of contact that will checked regularly and replied to promptly.

Name: *

As it appears on your Government ID

Middle Name:

Last Name: *

As it appears on your Government ID

Gender: * Gender:

Date of Birth: mm/dd/yyyy *

Race / Ethnicity *

This information is ONLY for the SEEDS program.

Academic Institution *

Academic Year:

Major *

Expected Graduation Date: (mm/yyyy) *

Please specify race or ethnicity

Mailing Address: *

Mailing Address 2:

City: *

State *

Zip Code *

Cell Phone: xxx-xxx-xxxx *

Telephone Number: xxx-xxx-xxxx

Personal Email Address: *

School Email Address:

Short Biography

Please write a short paragraph about yourself to share with the rest of the student participants. Introduce yourself, your academic and personal interests and any other cool facts about yourself that you would like to share. This information will be sent our to all participants before the meeting.

Copy and Paste a Short Biography here: *

ESA Annual Meeting: Science Presentation

Please give us as much information about your presentation (either oral or poster) at the meeting. This information will be sent out to all participants before the meeting. If you do not have a presentation - leave it blank

Author(s) and Institutions

List the author(s) and their institutions.

Title of the presentation:

Scheduled data and time:

Presentation ID number: (xxxxx) five digit number - check your email confirmation from Confex

Personal Considerations

The SEEDS program is a minority serving program. The information that you provide is used to measure our programs efforts to increase minority representation within the science of ecology. The information is for SEEDS program use only and is not shared or sold. We appreciate your help!

Are you a first generation college student? *

Yes

No

Are your eligible for the Federal PELL Grant Program? *

Yes

No

Are you a veteran of the U.S. Armed Forces? *

Yes

No

Are you affiliated with a federally-recognized tribe? *

Yes

No

Are you a tribal member?

Yes

No

Name of tribe: *

Emergency Contact

Full Name: First and Last *

Relationship to you: Parent, Spouse, Partner *

Mailing Address: *

Mailing Address 2:

City *

State *

Zip Code *

Cell Phone: xxx-xxx-xxxx *

Alternate Phone: xxx-xxx-xxxx

Email Address: *

Accident Waiver and Release of Responsibility

2021 ESA Annual Meeting

VIRUAL

August 2-6, 2021

I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING AND/OR VOLUNTEERING IN THIS ACTIVITY OR EVENT, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained or controlled by them or because of their possible liability without fault.

I certify that I am physically fit, have sufficiently prepared or trained for participation in the activity or event and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my participation in this activity or event.

I acknowledge that this Accident Waiver and Release of Liability form will be used by the event holders, sponsors and organizers of the activity or event in which I may participate, and that it will govern my actions and responsibilities at said activity or event.

In consideration of my application and permitting me to participate in this event, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: (A) I WAIVE, RELEASE AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft or actions of any kind which may hereafter occur to me including my traveling to and from this event, THE FOLLOWING ENTITIES OR PERSONS:

The Ecological Society of America, Inc., its directors, officers, employees, volunteers, representatives, and agents, the activity or event holders, activity or event sponsors, activity or event volunteers;

(B) INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity or event, whether caused by the negligence of release or otherwise.

I acknowledge that the Ecological Society of America and its directors, officers, volunteers, representatives, and agents are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific event or activity on behalf of the Ecological Society of America.

I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident and/or illness during this activity or event.

I understand that at this event or related activities, I may be photographed. I agree to allow my photo, video, or film likeness to be used for any legitimate purpose by the event holders, producers, sponsors, organizers, and assigns.

The accident Waiver and Release of Liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.

I CERTIFY THAT I HAVE READ THIS DOCUMENT; AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL.

Full Name: *

Age: *

Date: mm/dd/yyyy *

Participant Certification

I have read and checked this form for omissions and errors. To the best of my knowledge, the information is complete and correct. I understand that the inclusion by me of false information or the failure to report all information requested in this application could disqualify me for further opportunities with the Ecological Society of America's SEEDS Program.

Do you agree? *

Yes

No

Date

Minority Ecologists Forum Travel Award Application