MINNESOTA MANUSCRIPT RESEARCH LABORATORY WORKSHOP June 1-6, 2014 — APPLICATION Please fill out this form or send by fax, mail, or email to: CENTER FOR MEDIEVAL STUDIES University of Minnesota — 1030 Heller Hall 271 19th Avenue S, Minneapolis, MN 55455 Tel. (612) 626-0805 — Email: [email protected] Full Name _____________________________________________________________________ Address _______________________________________________________________________ _______________________________________________________________________ Phone (home): _____________________________ (cell):________________________________ E-mail Address: _________________________________________________________________ Are you registered as a full-time University of Minnesota student in Spring semester, 2014? (please circle one) Yes No If so, what degree are you seeking? (please circle one) M.A. Ph.D. Other What department or program are you registered in (Spring 2014)? __________________________ Are you now officially registered for the graduate minor in Medieval Studies at the University of Minnesota? (please circle one) Yes No Name, phone number and e-mail address of faculty advisor: _______________________________ ______________________________________________________________________________ Please describe your general or specific area(s) of research interest: If you are a graduate student, have you chosen a thesis or dissertation topic? If so, please describe: Please describe briefly the most recent papers you have written on topics related to Medieval or Classical Studies: What languages pertinent to Medieval or Classical Studies can you read (please indicate level of proficiency): Please indicate any other special interests or goals which bring you to this workshop: Do you have special needs which will need to be accommodated to make possible your full participation in the workshop or attendance at its locations, the James Ford Bell Library and the Hill Museum & Manuscript Library (e.g., mobility, vision, hearing challenges, diet restrictions)? If so, please describe briefly or attach full description. Do you have medical insurance in effect which will meet your needs while attending the workshop? Yes / No If yes, please give source, name and contact information of provider. Source or plan name: _____________________________________________________________ Health care provider: _____________________________________________________________ Address: ________________________________________________________________ Phone: __________________________________________________________________ Emergency contact: ______________________________ Relationship: _____________________ Phone Numbers: ________________________________________________________________ **Workshop Fee: [ ] WORKSHOP ONLY (no room or meals): $400 **Please note – Workshop sessions are at the James Ford Bell Library on the West Bank of the University of Minnesota (Minneapolis). Housing and meals are not offered through the workshop this year, but if needed, please inquire for recommendations. How will you pay the fee for room, board and activities? (please check one) [ ] I am officially registered for the PhD or MA minor in Medieval Studies at the University of Minnesota and request payment of my fees by CMS. [ ] I am a registered University of Minnesota student (Spring 2014) and will make arrangements for my workshop fees to be paid by my department. Contact person for payment within department: Name: ______________________________ E-Mail: _______________________ Phone: ____________________________________________________________ University Account Number: __________________________________________ [ ] I will pay by check, which must be received by the Center for Medieval Studies within two weeks after I am notified of my acceptance into the workshop. I understand that if payment is not received by that time, my space may not be held. Full refunds may not be available after May 15.