Student Information Form

NAME OF STUDENT (as it is to appear on certificate): _________________________________________

LOCAL ADDRESS: ___________________________________________________________________

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EMAIL ADDRESS: ___________________________________________________________________

TELEPHONE: _________________________________________________________________

PRESENTATION FORMAT: ____ Oral ____ Poster

TITLE OF PRESENTATION: ____________________________________________________________

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EQUIPMENT NEEDED: ___ Computer/Projection System ___ VCR/TV
(Oral presentations only!)
___ Overhead Projector ___ Other _________________

NAMES AND ADDRESSES OF PARENTS OR GUESTS TO WHOM SYMPOSIUM INVITATIONS ARE TO BE SENT:

TITLE (Dr./Mr./Mrs./Ms.): ______ NAME: _________________________________________________

ADDRESS: _________________________________________________________________________

___________________________________________________________________________________

TITLE (Dr./Mr./Mrs./Ms.): ______ NAME: _________________________________________________

ADDRESS: __________________________________________________________________________

___________________________________________________________________________________

TITLE (Dr./Mr./Mrs./Ms.): ______ NAME: _________________________________________________

ADDRESS: _________________________________________________________________________

___________________________________________________________________________________

NAME OF FACULTY SPONSOR: ________________________________________________________

DEPARTMENT OF FACULTY SPONSOR: _________________________________________________