Form 1 HiSTEP - Orientation

HISTEP ‐ ORIENTATION
OMB Clearance Number: 0925-0299
Expiration Date: 30-Jun-2019

STUDENT'S CONTACT INFORMATION
Student's First Name (Given Name):*

Student's Last Name (Family Name):*

Student's Preferred E‑mail Address:*

Student's Phone Number:*

STUDENT'S RESEARCH INTERESTS
STEM‑M Area of Interest:*

Research Interests:*

Short Biography:*

PARENT OR LEGAL GUARDIAN CONTACT INFORMATION
Parent or Legal Guardian First Name (Given Name):*

Parent or Legal Guardian Last Name (Family Name):*

Parent or Legal Guardian E‑mail Address:*

Parent or Legal Guardian Phone Number:*

Relationship to the Student:*

EVENT PREFERENCES
Orientation Date ‑ First Preference:*

Orientation Date ‑ Second Preference:

Orientation Date ‑ Third Preference:

Collection of this information is authorized by The Public Health Service Act, Section 410 (42 USC 285). Rights
of participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties
for not participating or withdrawing from the study at any time. The information collected in this study will
be kept private to the extent provided by law. Names and other identifiers will not appear in any report of the
study. Information provided will be combined for all participants and reported as summaries.