Last Name*:                                   

First Name*:                                  

University Attending*:                     

Major*:                                                                            

Major Professor*:                          

College or School*:                                                            (e.g., Engineering, Physics, Computer Science, etc)

Year of Study*:                                                                    (e.g., 1st year Ph.D., 2nd year Masters, etc)

Gender*:                                     MaleFemale

Ethnicity*:                                   Hispanic or LatinoNot Hispanic or Latino

Race*:                                         American Indian or Alaska Native Asian
(Select one or more)                     Black or African American           White
                                                  Native Hawaiian or Other Pacific Islander

Email*:                                        

Home Telephone*:                        

Cell Phone*:                                 

City or Airport you will fly out of*:  

Do you have personal laptop that will need internet access*: YesNo

Please submit 200 words describing about your interest to attend the workshop*: