WIN Registration Form

I am registering as a:
Name:
Street:
City:
State:
Zip:
Home Phone:
Work Phone:
Email:
College Major:
Race/Ethnicity:
I understand that the dates of the large-group meetings for 2008-09 are on Wednesdays: Sept 24, Nov 19. Jan. 21 and Mar. 18 6:00 - 8:30 pm. I commit to attending at least three of these meetings*. Yes

*Per participant feedback, an exception will be made ONLY for students who will be away for a project during one term and must miss the previous term’s meeting due to PQP. Students who have not participated in WIN before must attend ONE of four meetings on Wednesday, Sept 10: 10-11am , 12-1pm, 2-3pm or 4-5pm in the Campus Center Hagglund Room to receive an orientation to the WIN program.

In what cluster would you like to be placed? (Please note that like clusters may be combined.)
Other:
If appropriate, please select your second choice cluster (we make every attempt to place students in their first choice, it is sometimes necessary to place professionals in their second choice to provide all students with access to professionals)
Students: What term(s), if any, do you plan to be away during the 2008-2009 year? Term A
Term B
Term C
Term D
Term E

Professionals Only Section

Current title:
Current company:
College(s) attended:
At the end of the year, we would like to provide your supervisor with a letter commending your participation in the WIN Program. If we may do so, please provide your supervisor's contact information:
Name
Title
Company
Address Line 1
Address Line 2
City
State
Zip
 
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Last modified: July 24, 2007 13:43:08