Increasing Diversity in Science and Technology Studies

For Internal Use Only Status ______Date ______Status Change ______Date ______Attending: YES NO Forms Received: YES NO

Increasing Diversity in Science and Technology Studies 2015 Undergraduate Student Fellowship Application – Page 1 Please complete the information below using the Word form feature. Date:

Last Name First Name MI Nickname or Preferred First Name

Mailing Address City State ZipCode

Email Address Cell Phone Other Phone

(select year) School Year Major

Dietary Restrictions Gender

Do you identify as a person with a disability? Yes No If yes, please specify only as you feel comfortable.

Which of the following best describes your race and/or ethnicity?

African American/Black American Indian/Alaska Native Asian Native Hawaiian/Pacific Islander White/Caucasian Other Race (please describe): 2+ Races (please describe):

Are you of Spanish/Hispanic/Latino descent? Yes No

By initialing here, I confirm that I am an American citizen. By initialing here, I confirm that I am available and willing to travel to Washington, DC in June 2015 for one (1) week Please check the session you are available to attend June 7th through June 13th June 14th through June 20th Either Session

Two References are required (at least one referee must be an academic reference): Name: Name: 1 2

# Title: Title: e

c Department: Department: n e Institution: Institution: r e f Phone number: Phone number: e

R E-mail: E-mail:

PLEASE COMPLETE THE QUESTIONS ON PAGE 2.

Please send your completed application by e-mail as an attachment to [email protected] by Monday, March 16, 2015. Please include a CV or resume. Increasing Diversity in Science and Technology Studies 2015 Undergraduate Student Fellowship Application – Page 2

Last Name First Name MI

Personal Narrative

1. What past, current or prospective social, political, cultural and/or ethical issues related to science and technology interest you and why? (250 words)

2. Please tell us about yourself, and describe your professional development and/or career goals. How will this program help you achieve those goals? (500 words)

3. What courses in or related to science and technology studies have you taken at college? Examples may include: bioethics, history of science, science policy, science and technology studies, public health, history of medicine.

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