Summer Neuroscience Workshop Application

Name*

First Last

Salutation

Email*

Office Phone

Mobile Phone

Title

(Assistant, Associate or Full Professor, instructor, etc.)

I am a...*

University*

Department

University Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Does your school grant a PhD in your area?

Is your school an HBCU, Tribal or Community College?

High School

Department/subject

Grades taught (check all that apply)

High School Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender*

Are you a U.S. citizen?*

Ethnicity*

Have you participated in our Summer Workshop before?*

Please paste your personal statement below, including plans to integrate workshop modules into your course(s).*

Please use the space below to provide any other information you wish to share.

Upload Curriculum Vitae*

Must be a PDF file.

Upload unoffical transcript (for students only)

Must be a PDF file.

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