Form 1 Individual Student Registration

NIH COMMUNITY COLLEGE DAY REGISTRATION
OMB Number: 0925-0740 (Expiration Date: May 2019)
Public reporting burden for this collection of information is estimated to average 3-minutes per submission.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974,
ATTN: PRA 0925-0740. Do not return the completed form to this address.
Type of Attendee:
Student

First Name (Given Name):

Last Name (Family Name):

Email Address:
(Check Accuracy)

College Name
other

College Name (if 'Other' was selected above):

Academic Major:
Other

Academic Major (other, please specify):

Which panel discussions do you prefer to attend?
(select up to two)
Careers in Biomedical Research
Careers in Nursing
Careers in Medicine, Dentistry, & Pharmacy
Health Careers for Mathematicians, Engineers, & Computer Scientists
Allied Health Careers
Careers in the Behavioral Sciences
How did you learn about the Community College Day?
other

feedback - Office of Intramural Training & Education at the National Institutes of Health

How did you learn about Community College Day? (please specify)

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