Register for the 2011 PCIA Forum

5th Partnership for Clean Indoor Air Forum

Registration Form

Haga clic aquí para ver este formulario en Español

Register here to join the largest gathering of household energy and health leaders as more than 300 practitioners share the latest developments in technologies, fuels, monitoring and evaluation, commercialization, carbon financing, awareness raising, and research; and make new commitments to significantly reduce exposure to indoor air pollution (IAP) from cooking and heating practices.

Please submit one registration form per person. Online registration is available through January 17, 2011, or earlier if spaces are filled. While participation in the Forum is free of charge, participants are responsible for their own travel costs and other expenses, including lodging and incidentals. Airfare support is available for a limited number of participants. For those requesting financial assistance, the registration deadline is November 15, 2010. The Forum will be held primarily in English with simultaneous Spanish translation and separate English and Spanish sessions as appropriate.

Please note that this event is not a typical conference in which participants attend only a subset of sessions. This is a working group event and all participants are expected to participate and engage fully in all Forum discussions and sessions. We are expecting more interested participants then we can accommodate so please only register for this event if you are prepared to attend all sessions and actively participate in the Forum with a goal of furthering the PCIA mission of improving health, livelihood, and quality of life.

Please read the entire registration form, including the Financial Support Application Form if applicable, before beginning to fill it out, as entries cannot be saved for later completion. Before beginning this form, you should have on hand:

A 75-word roster description
An electronic photo of yourself
If applying for financial support, an airfare quote
If applying for financial support, answers to the Financial Support Application Form
If applying for financial support, you will need to have submitted a 2009 results report and updated your Partner Profile in the last 12 months.
To submit your 2009 results report please visit ../..//results/2009/submit

You should receive an email shortly after registration submission containing the registration information you entered; please review the email for accuracy and contact us at moderator@pciaonline.org with any questions. If you do not receive the confirmation email it is unlikely that your registration was received, in which case please contact us at moderator@pciaonline.org.

Fields marked (*) are required. This registration form may take up to 15 minutes to complete once narrative responses have been prepared. This Forum is intended for PCIA Partners. If your organization is not yet registered as a PCIA Partner, please first visit: www.pciaonline.org/becomeapartner to join.

For best results, please log-in (at ../../) before submitting this form.

Title: *

First Name: *

Last Name: *

Organization: *

Organization Type: *

Other Organization Type:

Organization Website:

Job Title: *

Job Description:

Please provide a brief one-sentence description of your job responsibilities

PCIA Membership

This Forum is intended for PCIA Partners. If your organization is not already a Partner, please join the Partnership for Clean Indoor Air at ../..//becomeapartner.

Are you a Partner?: *

Yes

Has your organization updated its Partner Profile in the last 12 months?:

Yes

No (please update your profile prior to the Forum)

Has your organization submitted its 2009 results reporting?:

Yes

No (please go to: ../..//results/2009/submit to submit your results prior to the Forum)

Language

Do you require translation from English to Spanish: *

Yes

Personal Contact Information

Address Line 1: *

Address Line 2:

City: *

US State:

Do not select a state if you are located outside of the USA

Non-US State or Province, if applicable:

Zip/Postal Code, if applicable:

Country: *

Telephone: *

(country code-area code-number)

email: *

Registration confirmation will be sent to this address from moderator@pciaonline.org. Please add moderator@pciaonline.org to your electronic address book to ensure that the confirmation email does not get blocked by a SPAM filter.

Participant Roster

We are compiling a Participant Roster with an organization description (one per organization) and a photograph of each participant to distribute at the Forum to facilitate networking. This will be a key networking resource during the Forum, so please submit a great first impression of your organization for others to read! Please describe your organization’s mission and corresponding results related to household energy and health. If you are an independent consultant or researcher, specify current activities related to household energy and health. Limit description to 75 words. Only one description per organization, please; if someone other than you will be submitting your organization's description, please enter their name below. See example:

Practical Action demonstrates and advocates the sustainable use of technology to reduce poverty in developing countries. Currently, Practical Action is supporting scaling-up of successful indoor smoke alleviating technologies through awareness creation, revolving funds, marketing strategies, policy advocacy, and pollution and health monitoring. Practical Action Nepal plans to help 21,000 vulnerable women and children in six districts achieve improved health through improved indoor air quality, household sanitation, safe drinking water and clean household energy by 2012.

To see last year’s Roster click here: ../..//files/2009_PCIA_Forum_Roster.pdf

Description for Participant Roster: *

Participant Photo:

Upload your photo (one per participant) for the Participant Roster. The photo must be in .jpg format with a minimum resolution of 250x250. Please limit the file size to less than 1 megabyte (1MB). If you have any trouble uploading your photo you may email it separately to moderator@pciaonline.org.

Poster Exhibition

The Forum poster session is an opportunity for you to network and share the story of your important work with other participants. The posters will remain on exhibit during coffee breaks throughout the Forum. We will provide an easel for you to display your poster, story board, and pictures. There will also be space to display stoves and other printed materials. PCIA will print posters submitted electronically using the templates provided at ../..//2011ForumPosters; Partners are otherwise welcome to print and bring their own posters. To reserve a space for your poster you must click yes below.

Poster:

Yes

If you would like to submit or bring a poster for display, please reserve your spot by clicking yes above.

Film Festival

One evening during the Forum will be reserved for a PCIA film festival highlighting Partner activities and results. Interested Partners will be asked to submit their films ahead of time, and the Forum planning committee will select some number of submitted films to be shown at the festival. We will provide more information about submitting films to those who check yes below.

Film:

Yes

Please indicate whether you plan to submit a film

Kick-off Event

A Forum kick-off event will be held on Monday, February 21st at 9:00 AM, at the Museo de la Nacion in Lima, Peru.

The objectives of the event are to:

Present the advances of the policy framework for the “Half Million Improved Stoves for a Smokeless Peru” campaign at the different levels of government
Demonstrate evidence of the health impact from the use of improved stoves
Present results from the process of certifying and installing improved stoves
Get commitments from the presidential candidates to incorporate financial support for improved stoves in their government plans

Participants will include government authorities from central, regional and local governments, Presidential candidates, PCIA leadership and invitees, and representatives from the campaign.

Transportation will be provided from El Pueblo to the downtown Lima location of the kick-off event.

Do you plan to attend the kick-off event?:

Yes

Field Trip

A field trip will be organized on Thursday February 24th to give participants an opportunity to visit a local improved stove program near Lima. This will be a day-long trip. Multiple trip options will be offered; further information is provided in the logistics packet available at ../..//2011ForumLogistics, and additional details will be provided at the Forum.

Field Trip:

Yes

Please indicate whether you would like to participate in the field trip

Visa Requirement

Based on our experience, visa processing can sometimes take more than a month. We recommend you apply for a visa as soon as possible. Contact the Peruvian consulate in your home country for more information about applying for a visa. To find out if you need a visa, visit: http://www.rree.gob.pe/portal/aconsular.nsf/bd437a0309e5e7be05256bff006da083/a086a1dda82ff807052574490075bc48/$FILE/VisasXExtranJul2009.pdf. An invitation letter will be mailed to those who check Yes below.

Is a visa required for you to travel to Peru?:

Yes

If you plan to travel through the United States as a stopover into Lima, you will be required to obtain a U.S. Transit Visa. U.S. Transit Visas may be difficult to obtain. Therefore we encourage Partners who do not already have a U.S. Transit Visa to fly through Mexico or Brazil rather than the U.S.

Please indicate if you already have a US Transit Visa:

Yes

Food and Lodging

The Forum will be held at El Pueblo Resort and Conference Center, which can accommodate all Forum participants. All Partners are responsible for paying for their own accommodations. PCIA will send hotel reservation requests on behalf of those who enter their information at ../..//2011ForumLodging during the month of January. An email announcement will be sent to all registered participants when the lodging form is posted. For shared lodging options, participants will be randomly assigned same-gender roommates unless the name of another participant with whom you have agreed to share a room is provided, in which case the hotel will try to accommodate the request. Reservation confirmation will be sent to you by the hotel after registration has closed in January. Please indicate below the type of room you are likely to request, so that we may block the right numbers of each kind of room ahead of time. This is NOT a reservation.

Lodging Preference:

All rooms at El Pueblo include a complimentary continental breakfast. Peruvian nationals will need to pay an additional 19% tax added to the per-night price shown.

Food Preference:

No restrictions

Vegetarian

Other dietary restrictions:

Please indicate which previous PCIA Forum(s) you have participated in, if any:

New York (2003)

Morocco (2005)

India (2007)

Uganda (2009)

How did you find out about the Forum?:

PCIA Bulletin

PCIA website

PCIA email

PCIA event (please specify below)

Other list serves (please specify below)

Other websites (please specify below)

Other sources (please specify below)

If your response includes "please specify", add details here:

Financial Support

Airfare support is available for a limited number of participants, and is typically limited to one scholarship per Partner organization. Priority will be given to active PCIA Partners who are implementing household energy and health projects in developing countries, and to those who apply early. Review of financial support requests will be ongoing, and preference will be given to early applicants. The early deadline for financial support is October 4, 2010; decisions on applications submitted by this date will be made by October 29, 2010. The final deadline for financial support consideration is November 15, 2010; decisions will be made by December 10, 2010.

If applying for financial support, you will need to have submitted a 2009 results report and updated your Partner Profile in the last 12 months.
To submit your 2009 results report please visit ../..//results/2009/submit

Do you want to apply for financial support?:

Yes

If you selected 'yes' you must fill out an application for financial support by clicking on the yellow bar below.

Click here if you require an airfare scholarship for travel to the Forum

Financial Support Application Form

While participation in the Forum is free of charge, participants are responsible for their own travel costs and other expenses, including lodging and incidentals. Airfare support is available for a limited number of participants. Priority will be given to active PCIA Partners who are implementing household energy and health projects in developing countries, and to those who apply early. Please note that the Forum will be conducted primarily in English with simultaneous Spanish translation and parallel sessions in Spanish as appropriate. The following criteria will be used to select participants to receive support:

Membership in PCIA;
The mission, goals, and results of your household energy and health program;
You and/or your organization’s participation in PCIA to date;
Your organization’s submission of 2009 results;
Your organization’s updating of its PCIA Partnr Profile in the last 12 months;
Your commitment to further the mission of the Partnership, contributing your resources and expertise to increase the use of affordable, reliable, clean, efficient, and safe home cooking and heating practices, and how participation in the Forum will help you achieve this.

Please note that participants awarded airfare support will be expected to actively participants in ALL Forum sessions, lead some activities as appropriate, and complete a brief report within 15 days of the Forum.

If you are awarded travel support, and Winrock can find an airfare quote similar to the one you provided, or lower in cost, we will purchase the ticket for you. If not, we may ask you to purchase the ticket yourself, in which case Winrock will reimburse you following the event, once we have your ticket receipt. We will purchase tickets that arrive in Lima on Sunday February 20th, and leave on Sunday February 27th unless alternate dates are requested below. You may also share preferences on connections, which we will do our best to accommodate when possible.

Please provide an estimated airfare quote in U.S. dollars. The itinerary should be for round trip travel to and from Lima by the most direct route possible (economy class) and by the provisions set forth in the Fly America Act of 1974 (for more information, please visit http://www.ogc.doc.gov/ogc/fl/fald/itl/itlv14.pdf). Please be aware that if you do not have a U.S. Visa, you will not be able to stop over in the US during your flight. Please keep this in mind when looking at airfare estimates. Other options include flying through Brazil or Mexico. Note that financial support is limited to one person per organization. Please provide the requested information below.

1. Please describe the mission, goals, and results of your household energy and health program :

(max 200 words)

2. How have you and/or your organization participated in PCIA activities (e.g., workshops, Forum, Bulletins)? :

(max 100 words)

3. Please describe how you or your organization have worked to further the mission of the Partnership, and how participation in the Forum will help you better achieve this:

(max 100 words)

Flight preferences, if any:

Please provide an estimated airfare quote in U.S. Dollars: $

Do you have a US Visa (including transit visa)?:

Yes

Information on whether you have a visa will be used only to assess the feasibility of booking tickets that fly through the US if you are awarded support, and will not be used in considering your financial support application.

Kindly Register Before January 17, 2011. Please review your registration carefully before submitting, as your information can not be updated online once submitted. You may edit your registration after submission by emailing any updates to moderator@pciaonline.org.

By submitting this registration I confirm that I understand this is a working event, and that I intend to participate and engage fully in all Forum discussions and work sessions.