Symposium on Diversity Registration

CURS Presentation Registration for Symposium on Diversity
Name*

First NameLast Name
What institution are you from?*
What is the name of the institution?
Phone Number*
(000) 000-0000Format: (000) 000-0000.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Anticipated Graduation Date*

MonthDayYear
Gender Identity*
If you selected Other, please specify below:
Major*
Current Class Standing*
Current Cumulative GPA*
How many students will be presenting?*
YesNo
Who is the lead presenter?*
Presenter Number One
Name

First NameLast Name
Student ID Number
Email Address
example@example.com
Presenter Number Two
Name

First NameLast Name
Student ID Number
Email Address
example@example.com
Presenter Number Three
Name

First NameLast Name
Student ID Number
Email Address
example@example.com
Presenter Number Four
Name

First NameLast Name
Student ID Number
Email Address
example@example.com
Presenter Number Five
Name

First NameLast Name
Student ID Number
Email Address
example@example.com
Student Presentation Category*
YesNo
Course Title
Course Number
Name of Faculty Mentor

First NameLast Name
Email of Faculty Mentor
example@example.com
Phone Number of Faculty Mentor
(000) 000-0000Format: (000) 000-0000.
Department of Faculty Mentor
Name of Second Faculty Mentor

First NameLast Name
Email of Second Faculty Mentor
example@example.com
Phone Number of Second Faculty Mentor
Please enter a valid phone number.Format: (000) 000-0000.
Department of Second Faculty Mentor
OneTwo
Title of Presentation*
Presentation Abstract*
Should be Empty:

CURS Presentation Registration for Symposium on Diversity

Presenter Number One

Presenter Number Two

Presenter Number Three

Presenter Number Four

Presenter Number Five