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WIN Registration Form

Please note: We are no longer accepting student registrations, however we are still looking for Professionals interested in participating.

I am registering as a: Name: Street: City: State: Zip: Home Phone: Work Phone: Email: College Major: Race/Ethnicity: 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 2010-2011 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 Type in the following two words

WIN Registration Form

Please note: We are no longer accepting student registrations, however we are still looking for Professionals interested in participating.

Professionals Only Section

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:

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