First Name     

Middle Name   

Last Name     

Address Line 1   

Address Line 2   

City        State   

Sex    Male Female     Zip Code   

Email Address   

Phone Number   

Ethnicity (Check All That Apply)

    African American

    Native American

    Hispanic

    Native Pacific Islander

    White

    Other

U.S. Resident?        Yes No

New York State Resident?        Yes No

Special Needs?        No Yes

Please list any special needs here.

Where Are You Currently Attending School?

School Name   

City        State   

 

Education Completed (Check All That Apply)

    Some High School;  Current Grade    -- 9 10 11 12

           High School;  Grade Average   

              Freshman Year of College/University

    Sophomore Year of College/University

    Junior Year of College/University

    Senior Year of College/University

Cumulative College GPA:   

Anticipated Graduation Date   

 

How did you hear about the Buffalo Geosciences Program?

Flyer/Brochure School Presentation Course Advisor Professor/Faculty Member Friends/Other Students Website Mailings Other

If other, please specify: