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2017 MATC Scholars Program - Registration


Registration Deadline: Thursday, June 1, 2017




* Required

Section 1: General Information


First name: *
Middle name:
Last name: *
Current address 1:*
Current address 2:
Current city: *
Current state/province: *
Current zip: *
Permanent address 1:
Permanent address 2:
Permanent city:
Permanent state/province:
Permanent zip:
Cell phone number: *
Email: *
Date of birth (mm/dd/yyyy): *
Age: *
Gender: *
Race
Ethnicity:
Tribal Affliation:
Dietary restrictions/allergies (if any):
Medical conditions (if any):
T-shirt size: *

Check if you are a faculty. Skip Section 2.
Check if you are a speaker. Skip Section 2.

Section 2: Education


College/University: *

If your university is not listed here, please select 'other' in the drop-down and include your college name in the additional information at the end of this registration page.

Recommending faculty name: *
Class Standing: *
Anticipated graduation date (mm/yyyy): *
Degree (Assc., B.Sc., B.A., etc): *
Major (Civil Engineering, Mechanical Engineering, etc): *
Cumulative Grade Point Average (CGPA): *

Section 3: Emergency Contact


Name: *
Phone number: *
Relationship: *

Section 4: Travel and Lodging Information


Note: Students are required to check in to the hotel in Lincoln, NE by 6.00 p.m. on Wednesday, September 27th, 2017, and attend the closing session at 12.00 p.m. on Saturday, September 30th, 2017.

Would you be: (check one box)*
Driving
Flying






Hotel room sharing (list name of other student if you have a preference):

Section 5: Additional Information/Comments


Include any information you wish to share with the program organizers in the box below: