Ohio Student Research Forum Student Registration

UNDERGRADUATE STUDENT REGISTRATION FORM
Areas marked with an asterisk (*) are required fields.

PART I - PERSONAL DATA
	Type your name as you would like it to appear on your name badge
First Name:*
Middle Name:
Last Name:*

Current Mailing Address:*

City:
State:
Zip:*
Phone:	xxx-xxx-xxxx
Campus E-Mail:*
Alternate Email:
	(ex: yahoo, hotmail, sbcglobal etc)
Permanent Address:*

City:
State:
Zip:*
Phone:*	xxx-xxx-xxxx
Alt Phone (Cell):	xxx-xxx-xxxx

Gender:*	Male Female

Race:*	African American Asian American Pacific Islander Native American White
	Other ( )
Ethnicity:*	Hispanic Non Hispanic

Citizenship:	US Citizen?		Ohio Resident?	Permanent Resident? (Green Card Holder)


Emergency Contact
Name:
Relationship:
Phone:	xxx-xxx-xxxx

PART II - ACCOMMODATIONS
Hotel	Will you need a hotel room?		Columbus area residents please read
	Yes No
Meal Preferences:	Vegetarian		Vegan
	Other ( )
Disability/Accessibility:	What kind of amenities do you require? Please explain.


Parking:	Will you need parking on campus? Yes No
	If you arrive by carpool, mark yes only if you are the driver.

PART III - ACADEMIC PROGRAM INFORMATION
Enrolled Institution:*
Research Institution:*
Department or Major: *
Expected Graduation:*
GPA:*	x.xx
Class Rank:*	First Year	Sophomore	Junior	Senior

PART IV - SUMMER INTERNSHIP INFORMATION
Mentor Faculty Rank:
Mentor Last Name:
Mentor First Name:
Mentor Institution:
Mentor Phone:	xxx-xxx-xxxx
Mentor E-Mail:


PART V - PARTICIPATION IN RESEARCH INTERNSHIP PROGRAMS
Have you previously participated in an academic year or summer research internship? Yes No
If so, please specify the the year(s) you participated in each program.

Program	Year(s) (Please separate multiple years with commas)
Glenn-Stokes
McNair
STARS
SROP
REU/NIH Supplement
Other (include program
and year)

PART VI - POSTER SESSION AND ORAL PRESENTATIONS All Glenn Stokes Summer Research Interns are required to present a research poster and submit an abstract. Other students are strongly encouraged to present a poster, but they are not required to do so. Poster Presentation Do you plan to present a poster at the Research Forum?* Yes No
Title of Research Poster
If you do not have a title for your poster at this time, you will receive a request for your title by email at a later date. Students presenting posters must also submit an abstract to the OSEA office. A Call for Abstracts email will be sent to you closer to the date of the Forum.

Glenn-Stokes seniors are required to present the results of their research orally on Friday, August 8. Other students are also invited to present their research. Since time is limited, selection of presenters will be made on a competitive basis. You will be notified by July 27 if you have been selected to present your research. Are you a Glenn-Stokes Intern in your Senior year at your home institution? Yes No Are you interested in being considered to present your research orally? Yes No

Updated 6.26.08

Columbus area residents please read