2009 Lake Arrowhead Retreat
October 16-18, 2009
Registration Form
(A separate form must be completed for each person attending)
Registration Deadline: Monday, September 14, 2009

Name of Attendee:

Email address:

Gender:

Female Male

Check if applicable box:

Faculty

MBI Adminstrative Staff ⁽¹⁾

MBIDP Graduate Student ⁽¹⁾

Cell & Molecular Biology Training Grant Graduate Student ⁽¹⁾

Chemistry-Biology Interface Training Grant Graduate Student ⁽¹⁾

Postdoc, SRA, or Other Lab Personnel (PI named below) ⁽¹⁾

Spouse/Significant Other of another Attendee (Named below) ⁽²⁾

.............................................	⁽¹⁾PI/Faculty Supervisor:
.............................................	⁽²⁾Attending Spouse/ Significant Other:

GLOBAL COE PROGRAM PARTICIPANT (Specify sponsoring faculty member, named below) ⁽³⁾

.............................................

⁽³⁾Sponsoring faculty member:

Participation:

I have submitted an abstract for a TALK

I would like to present a POSTER, (and will e-mail the abstract of poster to mbigrad@mednet.ucla.edu by September 14)
Area of interest:

Attendance Only

Accommodations:

Rates indicated are per night and per person (where applicable). Please check each night you will need accommodations.

PARTICIPANT SINGLE OCCUPANCY- Faculty Member Only (space limited)
Rate: $210/per night
Reservations requested for Friday and/or Saturday

PARTICIPANT DOUBLE OCCUPANCY- a cabinmate will be assigned for you, unless a preference is identified below:
Rate: $180/per night
Reservations requested for Friday and/or Saturday

Preferred cabinmate's name:⁽⁴⁾

Is cabinmate your spouse/significant other? Yes No

NON-PARTICIPANT (FAMILY)- Non-participating spouses and children are welcome to attend, if space is available.
Advance registration and payment by personal check required.
Rate: $125/per spouse and children over 14 years
Rate: $75/per child up to 14 years
Reservations requested for Friday and/or Saturday

Please list children's names/ages:

PARTICIPANT ONLY - No Reservation for Lodging Required.
Will attend: Friday or Saturday

Payment (if applicable):

Personal Check

Costs covered as Members of:
      Space/Membership Committee
      MBI PhD Committee
      MBIDP Graduate Student, C&MB or CBI Training Grant Graduate Student

Recharge ID with information below

Account:

CC:

Fund:

Sub:

Example: Account: 444888, CC: 3A, Fund: 50505 Sub: 05

Dept. Accounting Contact's Name:

Phone:

Transportation:

I prefer to drive myself

I can drive and take passengers How many?

I need transportation

Dietary Restrictions:

No, none.

Yes, I have dietary restrictions, as listed:

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