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* 1. I am registering to mentor a student in the ...

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* 2. What is your last name?

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* 3. What is your first name?

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* 4. What is your professional degree, e.g., PhD, MD, DDS, etc?

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* 5. What is your email address?

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* 6. What is your phone number?

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* 7. What is your UT Health San Antonio department, center, or institute?

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* 8. Whose lab do you work in?

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* 9. Will your minor student be 16 years of age or older before beginning work in  
the lab?

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* 10. What is the name of the High School attended by your minor student?

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* 11. What is the location (city) of the High School attended by your minor student?

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* 12. What is the current High School level of your minor student?

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* 13. What is the first name of the minor student who will work with you this school year (2021-2022)?

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* 14. What is the last name of the minor student who will work with you this school year (2021-2022)?

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* 15. Expected start and end dates for the student (mm/dd:mm/dd)

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* 16. Will your student be requiring access to special doors or buildings on campus? Please give the door number below, if they do not require access, leave blank.

Thank you for providing information regarding your plans to mentor a minor student in the conduct of research in the UTHSCSA Workplace.

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