REU 2016 Registration Form

General Information

Welcome 2016 REUs. Please complete the following program registration form. Please note that the information provided will be held confidential.

If you have any questions please email to Juniper Lovato at juniper@santafe.edu or you can call her at (505) 946-2726

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* 1. Permanent address: (note: this address will appear on your stipend checks; if you plan to cash the checks at a local bank in Santa Fe, it must match the identification you will present to the bank)

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* 2. Please provide most current information below. Please note that this will be the information I will use to send you logistical information about the program.

Name: *

Company: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Country: *

Email Address: *

Phone Number: *

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* 3. Cell Phone Number

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* 4. University you are attending

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* 5. Date of Birth

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* 6. Social Security #:

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* 7. Gender

Male

Female

Transgendered

Other

REU 2016 Registration Form

General Information

Question Title

* 1. Permanent address: (note: this address will appear on your stipend checks; if you plan to cash the checks at a local bank in Santa Fe, it must match the identification you will present to the bank)

Question Title

* 2. Please provide most current information below. Please note that this will be the information I will use to send you logistical information about the program.

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* 3. Cell Phone Number

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* 4. University you are attending

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* 5. Date of Birth

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* 6. Social Security #:

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* 7. Gender

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* 8. Citizenship

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* 9. Who should be contacted in case of an emergency? (name, relationship to you, and phone number):

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* 10. Short Bio for the Wiki Page to share with other participants (please email me a photo to juniper@santafe.edu)

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* 11. Personal URL: