Academic Leadership Fellows Summer Institute

2024 Academic Leadership Fellows Summer Institute Registration Form
FELLOWS: Please input your email address and click the "Auto Complete Fields" button. (Please use your email address from your institution all in lowercase. Please note that auto complete function will not work if you did not register with us last year. If this is your first time registering with us, you may skip to the next field.)
Your email (Please enter all in lowercase and press the "Auto Complete Fields" button)
Your Consortium*
Your Institution *
Name*

First NameLast Name
Title*
Cell Phone Number (will not be shared)*
Please enter a valid phone number.
Email*
example@example.com
Andrea C. Hatcher
Andrea Kaston Tange
Anene Ejikeme
Azita Osanloo
Caroline Fache
Connie Kassor
Danny Barreto
Dayo Abah
Duchess Harris
Eric Henager
Eric Smaw
Jennifer Mitchell
Jessica Sierk
Judith Caballero
Katherine Walker
Kira Jumet
Laura Senio Blair
Louis Epstein
Marion Hourdequin
Mary I. Unger
Meira Z. Kensky
Michelle Hite
Oscar A. Pérez
Ron Watson
Ross Elfline
Ryan Raul Bañagale
Your picture from last year is in the bio above. Would you like to:*

Use your directory picture as it is currently.Submit a new picture. (Please note that picture must be a high resolution headshot in.jpg, .png or .bmp format)
Please upload your bio headshot.

(Please note that picture must be a high-resolution headshot in.jpg, .png or .bmp format)
File Upload*

Cancelof
Your bio from last year is above. Would you like to:*

Use your directory bio as it is currently.Submit new information. If you pick this, you will have to resubmit all sections,not just what you want changed.
Your Bio (limited to 300 words)*

0/300
Your Fellowship Project Description (limited to 150 words)*

0/150
Your Fun Fact (limited to 50 words)*

0/50
Preferred Name for Nametag*
Preferred Pronouns for Nametag*
Please confirm or update your dietary restrictions and your emergency contacts. If correct, you may leave them as they are.
Dietary Restrictions (If any)
Emergency Contact Name*
Emergency Contact Cell Phone Number*
Please enter a valid phone number.
Should be Empty:

2024 Academic Leadership Fellows Summer Institute Registration Form

Please upload your bio headshot.

Please confirm or update your dietary restrictions and your emergency contacts. If correct, you may leave them as they are.