Participant Information Request

Full name (for official government forms):

Name you would like to be called:

Personal Pronouns:

Mobile Phone/Best phone to reach you during the Institute:

Best Email to reach you for Institute information:

Emergency Contact Name:

Emergency Contact Relationship to You:

Emergency Contact Location (city/state):

Emergency Contact Mobile Phone:

Dietary restrictions and allergies (for allergies, please specify if cross-contamination is an issue).

Housing

Housing for participants is offered in the UC Berkeley Unit 3 dorms at a cost of $996 for a single and $720 for a shared room. The cost is for the entire duration of the program, June 12-24, 2022. If you are still deciding, please go ahead and select "Not sure" and fill in the rest of the form.
Housing Option:
please select from pulldown menuNot sure yetUC Berkeley Dormitory-singleUC Berkeley Dormitory-doubleNone-I will find my own housing

The UC Berkeley dorms offer an all-female floor, an all-male floor, and a Co-Ed accommodation where the entire floor and communal bathroom would be open to all gender identities or expressions. Please select the floors you are comfortable with below (you may select more than one):
All gender floorFemale floorMale floor

Covid-19 Vaccination Status (note-vaccination is mandatory to stay in the UC Berkeley Housing option, with limited exceptions. Please review the UC Berkeley Vaccination policy if you have any questions):
please select from pulldown menuFully VaccinatedNot fully vaccinated but will before arrivalNot vaccinatedPrefer not to say

If applicable, please upload your vaccination card or other proof of Covid-19 vaccination status (acceptable file types: PDF, JPG, PNG)

By clicking the box below, you agree to comply with all provisions of the UC Berkeley Vaccination policy.
I agree

Program Materials

Please provide a bio of 100 words or less

Please attach a photo of yourself for the website and printed materials (PNG or JPG format):

Portions of the Summer Institute may be video recorded and/or livestreamed. Please indicate whether you consent to appear in these recordings.
YesNo

Photographs will be taken throughout the Summer Institute by Mangalam Research Center (MRC) staff. Please indicate whether you consent for your image to appear on MRC social media, website, or other publicity.
YesNo

Please enter any requests for accommodations or any other requests or information you would like to share with us.

Financial

Please download a form W9 from the IRS website, complete, and upload it to the following secure Dropbox folder: https://www.dropbox.com/request/x1ICwl6KwB5zP4rESP6o. Please include your last name in the filename.