REGISTRATION FORM for:
 
        Functional MRI Visiting Fellowship Program
                         or
        Martinos Connectivity Course

NOTE: Please fill out brief "Biosketch" and optional photo, at the bottom of this page.

Preferred Date for fMRIVFP: Functional MRI Visiting Fellowship Program

Preferred Date for Connectivity Course

Course Fees

The fee for the program is $1500. A reduced rate of $1000 is available to graduate students with a letter of verification from their Department Chairman. NOTE: MD's and Phd's do not qualify for the graduate student rate and normally are expected to pay the full fee. However, if a post-doctoral applicant is paying out-of-pocket (rather than the more normal grant-funded or institutionally-funded payment) then a discounted rate of $1250 is available.

We need to receive your tuition payment promptly after you register (if your institution will be paying on your behalf, we will need a contact person from you to ensure that payment is 'in process'), in fairness to other people who may end up on a waiting list. Please contact us should special arrangements need to be made regarding payment. Course fees are refundable up to 30 days prior to the session. A $200 fee will be deducted, should you cancel and request a refund between 30 days and 21 days (3 weeks) prior to the program start. After that, the tuition can be applied to a future program, or can be 50% refunded.

Payment by Check

Make checks payable to: Massachusetts General Hospital

Mail checks to:

Stacey Ladieu
Athinoula A. Martinos Center for Biomedical Imaging
149 Thirteenth Street - Room 2301
Charlestown, MA 02129

Please be sure the NAME OF PARTICIPANT and the PROGRAM STARTING DATE are included with the check.
And be sure that it is sent to the attention of STACEY LADIEU for processing.

Payment by Credit Card

After completing registration, an e-mail will include url for paying via credit card.

Biosketch

Please include an informal statement describing your background (academic, clinical, research, industrial, other), your experience with functional neuroimaging, fMRI, and resting state connectivity analysis. This is also an opportunity to state what you most hope to get out of the program.

This biosketch will be distributed to the faculty and to other course participants. It should be no more than two paragraphs in length.

PLEASE: Make the biosketch informal. It is intended to introduce you to the other participants and staff, not to apply for a job.

We like to send out these biosketches to faculty, staff, and course participants, and it would be nice to be able to include a photograph. So, if you would be willing to, please submit your photo here (in .jpg format). Otherwise, you will have the option to e-mail a photograph after you have registered. Photographs should be sent to the course administrator, at the fMRIVFP e-mail address, shown below.