Cohort Cohort Please select which cohort you are applying for * Triangle (Raleigh, Durham, Chapel Hill, and surrounding areas) Triad (Greensboro, High Point, Winston-Salem, and surrounding areas) Pembroke (Robeson County, Cumberland County, and surrounding areas) Northeastern (Greenville, Elizabeth City, and surrounding areas) Contact Information Contact Information First Name * Last Name * Email Address * Re-enter Email Address * Phone Number * xxx-xxx-xxxx Address Line 1 * Address Line 2 City * State * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Preferred Videoconferencing Platform Skype Skype for Business Google Hangouts Facetime Other If you selected "Other", please describe What is your screen name for your preferred videoconferencing platform? Application Application Information Why are you interested in this program? * Have you participated in public outreach before? If so, what did you do? Select all that apply Visited schools Media interviews Blogging/social media Presented to elected officials Informal public education Other If you selected "Other", please describe Are you able to provide your own transportation to and from workshops and events? * Yes No How far are you willing to travel? * Parts of this program will require travel, in which case the program will provide compensation. An hour or less Up to 2 hours Up to 3 hours Up to 4 hours I can travel anywhere Please confirm the following: * I will be able to attend two workshop training sessions I will be able to complete three outreach activities I will communicate with program staff in a timely manner I will give advance notice if unexpected schedule changes prohibits attendance or impacts participation Education and Occupation Education/Occupation Are you currently a graduate student? * Yes No What school are you enrolled in? * What type of graduate program are you enrolled in? * M.A./M.S. Ph.D M.D. Other If you selected "Other", please describe When will you complete your graduate degree? * Within the scope of STEM, how would you classify your field of study? * Science Technology Engineering Mathematics Other If you selected "Other", please describe Please briefly describe your research * 100 characters or fewer What is the highest degree you have earned? * A.A B.A./B.S. M.A./M.S. Ph.D M.D. Other If you selected "Other", please describe What field is your highest degree in? * Science Technology Engineering Mathematics Other If you selected "Other", please describe What year did you earn your highest degree? * In which type of organization do you work? * Academic Institution Government organization or agency Private sector Where do you work? * What is your job title? * Please briefly describe what you do for a living * 100 characters or fewer Within the scope of STEM, how would you classify the discipline in which you work? * Science Technology Engineering Mathematics Other If you selected "Other", please describe Personal Information Personal Information Age * 18-22 23-29 30-44 45-59 60+ With which gender do you identify? * Male Female Other With which of these groups do you identify? * The IMPACTS Program prides itself on its diversity and having our scientists represent the diverse population of North Carolina. African American/African Caucasian/European Hispanic/Latino American Indian/Alaska Native Native Hawaiian/Other Pacific Islander Middle Eastern South Asian/Indian East Asian Prefer not to answer Other What t-shirt size do you wear? * - Select -XSSMLXLXXLXXXL Do you have any dietary restrictions? If so, please list them here. Do you have any allergies? If so, please list them here. Do you have any special needs or considerations that we need to know about? If so, please elaborate and provide suggestions for proper accommodations. Emergency contact Emergency Contact Information Name * Phone number * Relationship * How did you learn about the IMPACTS program? Website Email TV Radio Other If you selected "Other", please describe
