Kilby Reading Room Registration Form
Name:
*
First Name
Last Name
Email:
*
example@example.com
Form Type:
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Form Type:
I am...
*
A Wheaton College community member (current student, faculty, or staff)
A visitor, here for personal enrichment
A researcher, employing a proxy
A visitor, here for academic research (above the undergraduate level)
Enrolled in the Wade Center Continuing Scholars Program
Name of Proxy Researcher (if known):
First Name
Last Name
Total Number of Visitors (Including You):
*
Only visitors who share the same address may use the same form
Additional Visitor Names:
Address:
Street Address
Street Address Line 2
City
Region (if outside US or Canada)
Postal/Zip Code
Country:
State:
Province
State/Region/Province
Street Address
Street Address Line 2
City
Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Wheaton College Role:
*
Faculty
Staff
Undergraduate Student
Graduate Student
Department/Major:
Student ID (if applicable):
Date and Time of Visit
Date of Visit:
On/From:
*
/
Month
/
Day
Year
First (or only) date of visit
To:
/
Month
/
Day
Year
Leave blank if you are only here for the day specified above.
Estimated Time of Arrival (9am to 4pm only):
Hours Minutes
AM
PM
AM/PM Option
Purpose of Visit
Reason for Visit (choose the option that best applies):
*
Class
Proxy Research
Honors Thesis / Thesis / Dissertation
Other (please specify)
Publication
Personal Interest
Proxy Research on behalf of:
*
First Name
Last Name
Reason for Visit:
Class Professor:
Course Number (or title):
Author(s) of Interest (select any that apply):
C.S. Lewis
J.R.R. Tolkien
Dorothy L. Sayers
George MacDonald
G.K. Chesterton
Charles Williams
Owen Barfield
Other (please specify)
Other:
Topic(s):
Research Topic:
*
Affiliation:
*
Institution
Independent Scholar
Other (please specify)
Affiliated Institution Name:
*
(if applicable)
Other Affiliation:
Institutional Role:
Graduate Student
Faculty
Staff
Other (please specify)
Other Role:
Department:
What Graduate Degree Are You Pursuing?
Ex: M.A., Ph.D., M.Div., Psy.D., etc.
Research Questions/Area of Study:
*
Is your research project intended for publication?
Yes
No
Proposed Title of Publication:
*Expected Date of Publication:
*or date of completion for theses/dissertations
User Agreement
I agree that typing my name constitutes my digital signature:
*
First Name
Last Name
Form Date:
-
Month
-
Day
Year
Today's Date
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