Background Information First Name * Last Name * Student ID Number * Email Address * Cell Phone Number * Mailing Address (Street, City, State and Zip Code) * Please indicate the mailing address to where your reimbursement check should be sent (if funding is approved). Indicate School of Sociology Major * - Select -BA in SociologyBS in Care, Health & Society Indicate Minor (If Applicable) Indicate Secondary Major (If Applicable) Indicate Secondary Minor (if Applicable) Current Class Standing * - Select -JuniorSenior Cumulative GPA * Program Information What kind of program are you completing? * Academic Conference Workshop for skills development Program Location (City, State, Country) * Program Name * Semester Completing Program * Spring 2017 Summer 2017 Fall 2017 Program Start Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20162017201820192020 Program End Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20162017201820192020 If your airfare itinerary does not match your program start and end dates, please explain why here Expenses Airfare Amount * $ Conference/Worrkshop Fee Amount (if applicable) $ Are you currently receiving funding for this program from any other sources? * Yes No If yes, please list sources and amounts (If none, please type "NA".) * AttachmentsResume Resume * Please attach your resume as a PDF only.Files must be less than 2 MB.Allowed file types: pdf doc docx. Essay Statement Essay Statement * Please attach your essay statement as a PDF onlyFiles must be less than 2 MB.Allowed file types: pdf doc docx. DisclosureSCHOOL OF SOCIOLOGY DISCLOSURE I certify that the above information is true and accurate to the best of my knowledge. I understand that incorrect or missing information may make me ineligible for any funding in the School of Sociology. I understand that if I am selected as a recipient, I am responsible for food, transportation and personal expenses outside of the program fee costs and the airfare costs that will be covered by School of Sociology. I understand that while this program will not count for academic credit, I will still be required to participate in all program activities and complete all academic assignments given by my faculty leader. I understand that if I am selected as a recipient, I will be representing the University of Arizona and will comply with the Student Code of Conduct. Initials * Your initials indicate that you agree to the statement above Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year201820192020 Leave this field blank
