Registration and Travel Survey for the CESTI Fostering Action to Address Ethical and Societal Implications of Emerging Science, Technology, and Innovation in Health and Medicine Workshop (Planning Committee members, Speakers, Invited Guest)

Please fill out the response form below for the National Academies' workshop, titled "Fostering Action to Address Ethical and Societal Implications of Emerging Science, Technology, and Innovation in Health and Medicine" to be held May 14, 2024. For any questions, please reach out to Kimberly Ogun (KOgun@nas.edu).

2. Contact Information

Full name *This question is required.

Email address *This question is required.

Pronouns

Job title *This question is required.

Affiliation *This question is required.

Mailing address (street, apt/suite, city, state, zip, country) *This question is required.

Phone number *This question is required.

Assistant name and email (if applicable)

Please provide a biography (1-2 paragraphs) for use in the meeting materials, which will be posted to the event homepage.
*This question is required.

Please upload a professional headshot for use in the meeting materials and in the workshop's promotion. If you have trouble submitting a headshot, please email it to me directly at KOgun@nas.edu.

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Space Cell	In person	Virtual
Workshop – Tuesday, May 14, 9 – 5 pm (ET)	Workshop – Tuesday, May 14, 9 – 5 pm (ET): In person	Workshop – Tuesday, May 14, 9 – 5 pm (ET): Virtual

Continental breakfast, lunch, and refreshments will be provided during the meeting. Do you have any dietary restrictions (gluten-free, vegetarian)? If so, please describe.

Please read and sign the appropriate (federal employee or non-federal employee) Speaker Permission Form. This form allows us to post your slides on the meeting page following the meeting and, if appropriate, include information/figures in the final workshop proceedings publication. *This question is required.

Please select the appropriate Permission Form to sign: *This question is required.

National Academy of Sciences
Material Use License and Personal Release Form
Presentation Materials by Third Parties
(Not Agents of the NAS)

We are pleased that you have agreed to participate in the workshop Fostering Action to Address Ethical and Societal Implications of Emerging Science, Technology, and Innovation in Health and Medicine , to be held May 14, 2024 (“Activity”). The National Academy of Sciences on behalf of itself and its constituent units, including the National Academy of Engineering, the National Academy of Medicine and the National Research Council (hereafter “NAS” or “the organization”) may, for NAS tax-exempt purposes: (1) conduct this Activity using real-time internet or teleconference technology; (2) record the Activity, including your presentation; and (3) use still images or recordings (or portions thereof) from your presentation to promote or recap your presentation and/or participation in the Activity, including but not limited to making archival copies (including placement in a public access file created for this Activity), use on the NAS websites, and distribution via podcasts, social media, or other means (the “Purposes”).

Presentation Materials Use License
I agree that the NAS, for the full term of any copyright and any extensions thereto shall have a royalty-free, nonexclusive, irrevocable license to publish, reproduce, distribute, transmit, display, store, translate, edit, create derivative works from and otherwise use the materials presented at the Activity as described: audio recordings, transcriptions, vu-graphics, slides, and other materials (the “Presentation Materials”) in all forms, languages and media, whether now known or hereafter existing, solely for the Purposes as set forth above.

I confirm that the Presentation Materials are either: (1) fully original with me and have not been previously published (meaning the copyright interests in the Presentation Materials have not been assigned to a publisher or person/entity; or (2) not fully original with me (the Materials incorporate pre-existing materials, materials have been previously published, and/or contain material owned or controlled by others (including but not limited to my employer). If situation (2) applies, I confirm that I have obtained permission to use such materials and that I am authorized to grant the rights provided herein in connection with the Presentation Materials.

Personal Release
I hereby grant, in my personal capacity, the NAS permission to rights of my likeness, image, and sound of my voice as recorded and/or other biographical information (the “Likeness”) without payment or any other consideration, solely for the Purposes set forth above. I understand that this permission means that NAS may use, edit, copy, exhibit, publish or distribute my Likeness for the Purposes set forth above,

Neither the Presentation Materials nor my Likeness will be used in any manner that would suggest or imply endorsement of NAS or the Activity by me or my employer

This Materials Use License and Personal Release shall be governed by, and construed in accordance with, the laws of the District of Columbia, applicable to contracts entered into and to be fully performed therein.

I am of full legal age and have read this Materials Use License and Personal Release and am fully familiar with its contents.

Click to Download the Permission Form for Non-Federal Employees

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Signature of

National Academy of Sciences
Presentation Materials and Statement and Personal Release Form
Federal Government Employees
Acting in Official Capacity Only
(Not Agents of NAS)

We are pleased that you have agreed to participate in the workshop Fostering Action to Address Ethical and Societal Implications of Emerging Science, Technology, and Innovation in Health and Medicine , to be held May 14, 2024 (“Activity”).The National Academy of Sciences on behalf of itself and its constituent units, including the National Academy of Engineering and the National Academy of Medicine (hereafter “NAS” or “the organization”) may: (1) conduct this Activity using real-time internet or teleconference technology; (2) record the Activity, including your presentation; and (3) wish to use still images or recordings (or portions thereof) from your presentation to promote or recap your presentation and/or participation in the Activity for NAS tax-exempt purposes, including but not limited to making archival copies (including placement in a public access file created for this Activity), use on the NAS websites, and distribution via podcasts, social media, or other means (the “Purposes”).

Presentation Materials Statement
I confirm that the materials presented at the Meeting described herein as audio recordings, transcriptions, vu-graphics, slides, and other materials, (“Presentation Materials”) are either: (1) are fully original with me, created as part of my duties as an employee of the U.S. Government, such that neither I nor my employing agency are asserting any U.S. copyright protection in any of the Presentation Materials; or (2) not fully original with me (the Materials incorporate pre-existing materials, materials that have been previously published, and/or contain material owned or controlled by others. If situation (2) applies, I confirm that I have permission to use such materials and that I am authorized to grant the rights provided herein in connection with the Presentation Materials.

Personal Release
I hereby grant, in my personal capacity, the NAS permission to rights of my likeness, image, and sound of my voice as recorded and/or other biographical information (the “Likeness”) without payment or any other consideration, solely for the Purposes set forth above. I understand that this permission means that NAS may use, edit, copy, exhibit, publish or distribute my Likeness for the Purposes set forth above.

This Presentation Materials Statement shall be governed by, and construed in accordance with, Federal law as applicable to this Statement. The Personal Release shall be governed by, and construed in accordance with, the laws of the District of Columbia, applicable to contracts entered into and to be fully performed therein. I am of full legal age and have read this Presentation Materials Statement and Personal Release and am fully familiar with its contents.

Neither the Presentation Materials nor the Likeness will be used in any manner that would suggest or imply endorsement of NAS or the Activity by me or my employer.

Click to Download the Permission Form for Federal Employees

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Signature of