On-line Registration for Science Connection

S c i e n c e
Connection

Science Connection — Registration

How This Works

To join, you must fill out the form below. It has five sections:
1. your contact information
2. categorical and quantitative variables
3. text answers for your Biographical Profile
4. your "mini-profile"
5. payment and form submission.
None of your information will be made available to any other organization or business. (Ever!)

You will be notified your acceptance by e-mail the same day or by the next. You can then log into the Science Connection website Member Zone and peruse member info (mini-profiles, biographical profiles, and photos) and revise your own info.

Photographs

Photos (B&W or color) are optional and will appear with your biographical profile and with your mini-profile on the website. 77% of members provide a photo. Instructions for submitting a photo will be given after you submit this form.

When filling out the form ...

1. Please attend to your punctuation: lines will be reformatted.
2. You can move between fields using the [tab] key.
3. Length: you may exceed the allotted space, but overall your collective profile responses must not exceed 15 more lines than are displayed.
4. The asterisk (*) indicates required fields.

Are you: / joining for the first time / rejoining after an absence /

1. Contact info

The organizers of Science Connection must know your true identity. We need your name, address and phone number. This information will be treated as confidential except for the usage permissions you give below (and will not be made available to any third party).

First Name: Initials/middle name: Last Name: *

Title: / Dr / Mr. / Ms / Mrs / Miss /other: /

Postal address line 1: *

Postal address line 2:

City/town: *

State/Province/Territory (for members in the USA, Canada or Australia):
*

county/state/territory/etc.: (for other countries)

Zip/Postal Code: *

Country: USA or CANADA or *

If the country not listed above, enter here:

Phone: *

e-mail address: *

2nd (different) e-mail address:(explanation)

* Required field.

2. Categorical & quantitative variables

Sex: [ Female] [Male] Age: Marital status: /Single / Divorced / Widowed / Separated /			*
Contact info to appear on the profile form (choose at least one):		Postal address: Phone number: e-address:	*
Prefer initial contact from members by:		[ mail ] [ phone ] [ e-mail ]	*
Your chief interests in science/nature: natural history science in general mathematics physics astronomy geology chemistry molecular/cell biology population/organismal biology neuroscience medical science social science/psychology anthropology/archaeology economics computers technology/engineering agriculture veterinary medicine environmental/conservation issues			*
Height:		feet inches - or - cm
Weight:		lbs. - or - kg.
Do you smoke?		[Yes ] [No ] [Plan to quit ]	*
What university degree(s) have you attained?		[none ] [Bachelor's ] [Master's ] [PhD ] [MD ] [DVM ] [JD/LLB ] [MBA ] [currently undergraduate student ] ["some college" ] [nursing degree ] [other ]
Your religion:
Are/were you or will you be professionally involved in science/tech/nature interpretation? (elaboration)		[Yes ] [No ]	*
Are you open to long-distance contacts?		[Yes ] [No ] [Maybe ]	*
Are you open to the possibility of relocating?		[Yes ] [No ] [Maybe ]
Children	Do you have dependent child/children?	[Yes ] [No ]
	Do you have grown child/children?	[Yes ] [No ]
	Are you interested in having kids:	[ Yes ] [ Maybe ] [ No or not applicable ]
	Are you open to a prospective partner with children?	[ Yes ] [ Maybe ] [ No or not applicable ]
Are you interested in contacting/being contacted by members of the same sex? (explanation)		[ Yes ] [ No ]

3. Biographical Profile - text answers

Name on your profile: *
(Use full name, first name only, or pseudonym; most members give their real full or first name.)

Age on your profile: * (It is okay to be vague about age, e.g. 60+, 30s)

Education: *

Occupation: *

Religion:

Particular interests in science and/or natural history:

Other interests & pastimes:

Preferred reading material or information sources:

Favorite books, writers, or films:

Tastes in music:

What are your greatest sources of enjoyment?

What characteristics do you consider important in a prospective mate or friend?

Comments re long-distance contacts and relocation (e.g. geographic area of interest):

Additional comments (e.g. future plans and aspirations, children, political leanings):

4. Mini-Profile

Format: Age, marital status (S=single[never married]; D=divorced; W=widowed; X=divorce pending), height (optional), weight (optional), occupation, etc...

Example: 43,D,5'10'',165lbs. Professor of Zoology; research interests in behavioral ecol. of bats. Enjoy sailing, cross-country skiing, movies, jazz (play piano), reading (fiction, science, history), New Yorker cartoons. Moderately sociable; like children. Would like to meet women with an interest in the natural sciences. Madison, WI.

Enter your mini-profile here: (DO NOT EXCEED 6 LINES) *

Mini-profile location:
City and state/province (2-letter code) or region; include country if outside USA/Canada
*

Mini-profile Examples We present examples of members' mini-profiles to prospective members on our public website. Please indicate below whether we may use your mini-profile as an example, and if so, whether your location should be included or excluded. (You can change these options any time online.)

Allow use of your mini-profile as example on the website: [ yes ] [ no ]

If it is to be used as an example, should your location be: [ included ] [ excluded ]

5. Payment and form submission

Payment
I wish to subscribe for (see membership fees):
[ Annual membership ] ($65.00)
[ 3-month membership ] $30.00)
Currency: Canadian dollars for Canadians; U.S. dollars for all others

Please charge my payment to my Visa, MasterCard or American Express* account #
, expiry
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I am mailing payment (cheque or money order)

I learned of Science Connection from the following publication(s) or other source:
or other:

I have read and accept Science Connection's Terms and Policies Relating to Membership

Send completed form to Science Connection: --- or --- Clear all fields of above form:

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First Name: Initials/middle name: Last Name:		*
Title:	/ Dr / Mr. / Ms / Mrs / Miss /other: /
Postal address line 1:		*
Postal address line 2:
City/town:		*
State/Province/Territory (for members in the USA, Canada or Australia):		*
county/state/territory/etc.:	(for other countries)
Zip/Postal Code:		*
Country:	USA or CANADA or	*
If the country not listed above, enter here:
Phone:		*
e-mail address:		*
2nd (different) e-mail address:(explanation)

Allow use of your mini-profile as example on the website:			[ yes ] [ no ]
If it is to be used as an example, should your location be:			[ included ] [ excluded ]