Looking Back, Looking Ahead: Developing and Sustaining Community-Based Pedagogy at ACM Campuses Step 1 of 3 33% ACM will host “Looking Back, Looking Ahead: Developing and Sustaining Community-Based Pedagogy at ACM Campuses” in downtown Chicago at The Summit, from 9:00 a.m. on Thursday, September 26, through 1:00 p.m. on Friday, September 27, 2024. (NOTE: ACM will cover and/or reimburse all reasonable expenses associated with your participation in the workshop, including roundtrip travel to Chicago, meals, and up to two nights of hotel accommodation). Please complete this registration form no later than August 2, 2024. If you have any questions, you can contact Allen Linton II at alinton@acm.edu.Name(Required) First Last Institution(Required)Beloit CollegeCarleton CollegeCoe CollegeColorado CollegeCornell CollegeGrinnell CollegeKnox CollegeLake Forest CollegeLawrence UniversityLuther CollegeMacalester CollegeMonmouth CollegeRipon CollegeSt. Olaf CollegeACMOtherMobile Phone(Required) Email(Required) Title(Required) I would like a room booked on my behalf for the following days?(Required) Both Wednesday and Thursday Sept 25-26 Only Wednesday September 25 Only Thursday September 26 Do you need a flight to attend the conference? If yes, we will send information to you about ACM's travel agent whom you should use to book your flight.(Required) Yes No I will attend the following meals:(Required) Breakfast on Thursday, September 26 Lunch on Thursday, September 26 Dinner on Thursday, September 26 Breakfast Friday, September 27 Lunch on Friday, September 27 Select AllHave you participated in a community-based pedagogies project that ACM funded through either the Institutionalizing Community-Based Pedagogies initiative or the Faculty Career Enhancement (FaCE) program?(Required) Yes No Please list any dietary restrictions or food allergies (if applicable). Please list any accommodations you may need during the conference (nursing room, wheelchair accessible bathroom, etc.) Comments (examples: I can only attend the first day,etc.) Independent of ACM-funded the community-based pedagogies initiatives referenced above, have you participated in a community-based learning project on your campus? Yes No Please provide a BRIEF description of the project. (Four senteces or less) Associated Colleges of the Midwest (ACM) Media Release FormThank you for your participation in an ACM-related activity. On occasion, representatives from the ACM may wish to photograph, record video and/or audio, and/or interview those connected with our organization. As a nonprofit educational consortium, our goal is to highlight and showcase the work we are doing via our website, videos, emails, posters, brochures, social media, and other marketing materials. As a participant in an ACM activity, your likeness may be captured in photos, videos, or other mediums during the activity. Photos are typically posted directly to the ACM website and/or social media platforms and may also be used in publications such as brochures, flyers, and annual reports. Video content is typically posted on the ACM YouTube channel and embedded into the ACM website. Video content may or may not include captions or written transcriptions. Please complete the waiver below to confirm whether or not you give ACM your permission to use your name and likeness for the purposes described above. While our goal is to post as much web content as possible related to ACM activities, we also respect your right to privacy. Thank you for your cooperation and support. If you have any questions, please contact acm@acm.edu. I give the Associated Colleges of the Midwest (ACM) irrevocable right to use my name and likeness in any photograph, video, audio recording, or other medium in which I appear and for any lawful purpose, including illustration, promotion, advertising, or web content. I understand that these mediums may be edited, copied, exhibited, published, or distributed, and I waive the right to inspect or approve the finished product, including written material that may be created in connection therewith. I also waive any rights of compensation or ownership thereto. It is understood that my participation in these photographs and recordings is done of my own free will. By signing this form, I acknowledge that I have read and fully understand this release, and agree to be bound thereby. I hereby release ACM from any and all claims or liability arising from, or in connection with, ACM’s use of my likeness in these images or recordings.(Required) a. Yes, I agree to the above statement. b. I agree to the above statement but with the exception of the following (please specify below): c. No, I do not agree to the above statement. If you answered "b" to the question above, please explain your answer here. Full Name(Required) Date(Required) MM slash DD slash YYYY Electronic Signature Agreement(Required) I accept. I do not accept. By selecting the “I accept” button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. Δ
