California Forum for Diversity in Graduate Education

Spring 2013 Forum at University of California, Irvine
Saturday, April 27, 2013 -- 8:00 AM - 4:00 PM

Student Online Registration Form
  

Please fill out this form completely and submit your registration.
Required fields are marked with an asterisk (*).

First name*
Last name*
Middle Initial
Gender* Female  Male  
Date of Birth
  Why we ask for DOB
Street Address*
Address (cont.)
City*
State*
Zip Code*
Day Phone*
Please include area code and number
Evening Phone*
Please include area code and number
E-mail Address* Enter your email address to receive and e-mail confirmation:
E-mail Address* Please enter again your email address:
Emergency Contact Full Name*
Emergency Contact Phone*
Please include area code and number
College* Select the college or university you are currently attending:
Other College
Enter the name of your college if it is not in the list above
Current Major* Please select your current major:
If you selected "Other" above, please enter your major:
Additional Major Please select your additional major, if any:
If you selected "Other" above, please enter your major:
Field of Study* Select the general field of study which your major falls under:
Overall GPA*
On a 4.0 scale A=4, B=3, etc.
Class Level* Select your current class level:
Other Class Level If "Other", please specify:
Ethnicity*
If "other", please specify:
Special Programs Are you participating in any of these programs? Please click all that apply.
AGEP Student MBRS Student
CSU Alliance for Minority Participation McNair Scholar
UC Alliance for Minority Participation CA Pre-Doctoral Scholar
MESA, 4-year Institution EOP Student
MESA, Community College NIH Bridges Student
Gates Millennium Scholar Grad Equity Fellowship
SSS Student MARC Student
UC LEADS Scholar
First Member of Family
to Attend College*		 Are you the first member of your family to attend college?
Yes  No  
Graduate School* Do you plan to apply to graduate school?
Yes  No  Maybe  
If yes, for which academic year do you anticipate applying?
Please select your proposed graduate major:
If you selected "Other", please enter your grad major:
Select the general field of study which your graduate major falls under:
What is your ultimate degree objective?
Reasons for
Attending Forum		 Reasons for attending the Forum. Please mark all that apply.
Gain general information about graduate studies
Explore various graduate opportunities
Meet with recruiters from specific universities
Learn how to prepare for the GRE
Meet with graduate faculty and/or students
Learn about graduate study in specific disciplines
Learn about financial aid for graduate study
Informed About
Graduate Study*		 How informed are you about what is involved in graduate study?
Arriving By* Car
Chartered Bus (provided by your institution)
Special Needs Specify any accommodations that you will require on the day of the
Forum (If this does not apply to you, please leave blank.)
Motivations
for attending
graduate school*		 To what extent do the following reasons motivate you to attend graduate school?
(1 = not very motivating, 5 = very motivating)
To learn more about my subject area* 1  2  3  4  5  
To further my own personal growth* 1  2  3  4  5  
To have an opportunity to stay in school a little longer* 1  2  3  4  5  
To qualify for my chosen career* 1  2  3  4  5  
To increase my job opportunities* 1  2  3  4  5  
To attain a higher earning potential* 1  2  3  4  5  
To become a role model in my community* 1  2  3  4  5  
My family expects me to attend* 1  2  3  4  5  
Obstacles to
preparing for
graduate school*		 To what extent would you consider the following to be obstacles in preparing for graduate school?
(1 = not an obstacle, 5 = an extreme obstacle)
Undergraduate grades* 1  2  3  4  5  
Taking Standardized Tests (GRE, GMAT, etc.)* 1  2  3  4  5  
Finding faculty for recommendation letters* 1  2  3  4  5  
Financing graduate education* 1  2  3  4  5  
Choosing the right program/area of study* 1  2  3  4  5  
Selecting the right school* 1  2  3  4  5  
Obtaining guidance about the process* 1  2  3  4  5  
Completing the applications* 1  2  3  4  5  
Writing a statement of purpose* 1  2  3  4  5  
Obtaining college transcripts* 1  2  3  4  5  
Academic rigor of graduate school requirements* 1  2  3  4  5  
Family obligations/pressure* 1  2  3  4  5  
Relocating to another geographic area* 1  2  3  4  5  
Waiver of Liability,
Assumption of Risk, and
Indemnity Agreement		 In consideration of being permitted to participate in any way in the
California Forum for Diversity in Graduate Education
(hereinafter called "The Activity"), I, for myself, my heirs, personal
representatives or assigns, do hereby release, waive, discharge,
and covenant not to sue the UC, The Regents or the
Governing Board of University of California, Irvine,
its officers, employees, and agents from liability from any and all
claims including the negligence of the UC, The Regents or the
Governing Board of University of California, Irvine, its officers,
employees, and agents, resulting in personal injury, accidents
or illnesses (including death), and property loss arising from,
but not limited to, participation in The Activity.

Signature of Parent/Guardian of Minor:
*
Signature of Participant:
Assumption of Risks: Participation in The Activity carries with it
certain inherent risks that cannot be eliminated regardless of the care
taken to avoid injuries. The specific risks vary from one activity to
another, but the risks range from 1) minor injuries such as scratches,
bruises, and sprains 2) major injuries such as eye injury or loss of
sight, joint or back injuries, heart attacks, and concussions to
3) catastrophic injuries including paralysis and death.

I have read the previous paragraphs and I know, understand,
and appreciate these and other risks that are inherent in The
Activity. I hereby assert that my participation is voluntary and
that I knowingly assume all such risks.

Indemnification and Hold Harmless: I also agree to INDEMNIFY
AND HOLD the UC, The Regents or the Governing Board of
University of California, Irvine HARMLESS from any and all
claims, actions, suits, procedures, costs, expenses, damages and liabilities,
including attorney's fees brought as a result of my involvement
in The Activity and to reimburse them for any such expenses incurred.

Severability: The undersigned further expressly agrees that the
foregoing waiver and assumption of risks agreement is intended to be
as broad and inclusive as is permitted by the law of the State of
California and that if any portion thereof is held invalid, it is agreed
that the balance shall, notwithstanding, continue in full legal force
and effect.

Acknowledgment of Understanding: I have read this waiver of
liability, assumption of risk, and indemnity agreement, fully understand
its terms, and understand that I am giving up substantial rights,
including my right to sue. I acknowledge that I am signing the
agreement freely and voluntarily, and intend by my signature to be a
complete and unconditional release of all liability to the greatest
extent allowed by law.

Signature of Parent/Guardian of Minor:
Participant's Age (if minor):
*
Signature of Participant:
Video Audio Image
Release Form		 I grant permission to the California Forum for Diversity in Graduate Education
and University of California, Irvine, its employees and agents, to take
and use visual/audio images of me. Visual/audio images are any type of
recording, including but not limited to photographs, digital images, drawings,
renderings, voices, sounds, video recordings, audio clips or accompanying
written descriptions. The Forum and University of California, Irvine,
will not materially alter the original images. I agree that the Forum
and University of California, Irvine, own the images and all rights related to them.
The images may be used in any manner or media without notifying me, such as
university-sponsored web sites, publications, promotions, broadcasts,
advertisements, posters and theater slides, as well as for non-university uses.
I waive any right to inspect or approve the finished images or any printed or
electronic matter that may be used with them, or to be compensated for them.

I release the Forum and University of California, Irvine, and its employees and agents,
including any firm authorized to publish and/or distribute a finished product
containing the images, from any claims, damages or liability which I may ever
have in connection with the taking of use of the images or printed material
used with the images.

I am at least 18 years of age and competent to sign this release. I have read
this release before signing, I understand its contents, meaning and impact, and
I freely accept the terms.
*
Signature of Participant:
Save Your Registration* I agree to allow the Forum Coordinator to share any or all
of the information on this form with any of the educational
institutions participating in the California Forum for Diversity
in Graduate Education.

I agree to the above terms.