Immersion Application UUIDWorkshop:*Select a WorkshopPower connection | $1,200.00Connect to care | $2,500.00Connection is key | $2,600.47Workshop price does not include tax, travel or accommodations. Payment not required until Application has been Accepted.Workshop Date:*Select workshop datesJanuary 09 - 10, 2020 | New York CityMarch 12 - 13, 2020 | New York CityJune 04 - 05, 2020 | CaliforniaOctober 01 - 02, 2020 | CaliforniaOctober 22 - 23, 2020 | New York CityDecember 03 - 04, 2020 | CaliforniaFirst Name:*Last Name:*Position / Title:*Email:* Phone Number:*Power ConnectionInstitution / Company:*Department:*Have you ever attended an Alda Center / ACT workshop before?*YesNoWhat is your motivation for attending this workshop?*What are your main communication challenges?*What obstacles/challenges do you see facing Women in STEM?*What solutions have you seen work well (for yourself or others) to address some of the obstacles/challenges you listed in the previous question?*At your discretion, please share situations or conversations in your workplace that you have difficulty navigating. We may anonymously use these examples during the workshop.*Please provide a brief biography (100 words). This information will be available to your instructors and fellow participants on the day of the workshop.*Connect to careAddress:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Degree:*Medical Specialty:*Do you have any restrictions (e.g. dietary, physical) that we should be aware of?Please provide your management title(s):*How did you learn of this program?*Describe your health care organization:*Its purpose; its services and patients; several measures of its size (e.g., annual budget, revenues, expenditures, # employees, patients or beds); medical school affiliation (if any)Please describe your role in the health care organization, including current responsibilities in each of these areas: Academic, Research, Clinical, Other:*List the top three management challenges you are facing:*(limit response to 350 characters including spaces)Provide the number and type of individuals or groups you supervise as well as the number of patients (e.g., beds, practices, etc.) in your service:*Name, title/position of individual(s) to whom you report:*Names of principal committees on which you sit:*Please provide a brief biography (100 words). This information will be available to your instructors and fellow participants on the day of the workshop.*Program fee will be paid by (Name, Email, Institution):*Connection is KeyYour Institution / University / Company*What would you like to learn from this workshop experience?*What is your STEM field of study or research?*How did you first hear about the Alan Alda Center for Communicating Science and these STEM workshops?*Do you have any restrictions (e.g. dietary, physical) that we should be aware of?Please provide a brief biography (100 words). This information will be available to your instructors and fellow participants on the day of the workshop.*General infoPlease indicate any dietary restrictions (check all that apply):* Vegetarian Vegan Kosher Halal Gluten-free Other None Do you have any special requirements we should be aware of in advance? Please describe.Additional comments or questions? This iframe contains the logic required to handle Ajax powered Gravity Forms.