Please fill out the following information as your application for a spot in Ithaca College delegation to The Diversity Student Summit on October 27, 2012 at SUNY Institute of Technology in Utica, NY.

Due to van size, we can only accommodate six students for this conference. Applications are due Monday, October 15, you will hear about the status of your application no later than Tuesday, October 16.

You can find out more information about this summit at htpp://

* 1. First Name

* 2. Last Name

* 3. Ithaca Email Address

* 4. Phone Number

* 5. What school is your primary degree part of?

* 6. Year In School

* 7. Are you a transfer student?

* 8. Will you be over 18 by October 27, 2012?
(If not, I will work with you to sign a different waiver. This will not impact your ability to attend this conference.)

* 9. List at least one way you have gotten involved in your new Ithaca College community since August?

* 10. In no more than four sentences, please tell us why you are interested in attending this Diversity Student Summit.

* 11. Emergency Contact Name (first and last)

* 12. Emergency Contact Phone