2022 LSUHSC-NO-New Orleans NIH-Blueprint, ENDURE, "Diversity in Neuroscience" Program Registration Form
Please complete the form below to apply for this program. Application deadline: March 31st, 2022, 11:59 PM.
I. PERSONAL INFORMATION
Full Name
*
First Name
Middle Name
Last Name
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail Address
*
example@example.com
Mobile Number
*
Phone Number
*
Alternate Phone Number
*
Emergency Contact Phone Number
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Relationship to Emergency Contact
*
Are you a U.S. citizen?
*
Yes
No
If you are not a U.S. citizen, please indicate status.
*
Copy of Driver's License or Government Issued Identification
*
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Immunization Records
*
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II. DEMOGRAPHICS
LSUHSC is an equal opportunity/affirmative action employer. Our training programs are supported in part through funding from the National Institututes of Health (NIH). The questions below will be used to assess and report to the NIH, the diversity of programmatic applicants and participants in our program. Responses are voluntary and will NOT influence assessment of your application.
Race/Ethnicity: Please select all that apply.
African-American
Alaskan Native
Caucasian/White
Middle Eastern
Native American
Native Hawaiian/Pacific Islander
Other
Are you from a disadvantaged background? (Ex. Are you the first-generation in your family to attend college?)
Please Select
Yes
No
Do you have a disability?
Please Select
Yes
No
If you responded "yes", will you require special accommodations?
Please Select
Yes
No
If special accommodation(s) is/are required, please describe.
III. ACADEMIC INFORMATION
Current Academic Institution
*
Academic Classification
*
Please Select
Freshman
Sophomore
Junior
Senior
Major
*
Minor
Have you participated previously in academic enrichment programs?
*
If applicable, where did you participate in the previous academic enrichment program?
*
Transcript 1 from current academic institution
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Transcript 2 (if applicable)
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Transcript 3 (if applicable)
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Reference No. 1
*
First Name
Last Name
Email Address for Reference No. 1
*
example@example.com
Reference No. 2
*
First Name
Last Name
Email Address for Reference No. 2
*
example@example.com
IV. RESEARCH INTEREST INFORMATION
Personal Statement 1: Please describe your interest in the NIH ENDURE at LSUHSC- New Orleans Program.
*
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Personal Statement 2: Please describe your interest in neuroscience research.
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