Increasing Diversity in Science and Technology Studies

Increasing Diversity in Science and Technology Studies

2017 Undergraduate Student Fellowship Application – Page 1

Please complete the information below using the Word form feature. Date:

Last Name / First Name / MI / Nickname or Preferred First Name
Mailing Address / City / State / ZipCode
Email Address / Cell Phone / Other Phone
(select year)FreshmanSophomoreJuniorSenior
School / Year / Major
Dietary Restrictions / Gender
Do you identify as a person with a disability? Yes No
If yes, please specify only as you feel comfortable.
Which of the following best describes your race and/or ethnicity?
African American/Black
American Indian/Alaska Native
Asian
Native Hawaiian/Pacific Islander
White/Caucasian
Other Race (please describe):
2+ Races (please describe):
Are you of Spanish/Hispanic/Latino descent? Yes No
By initialing here, I confirm that I am an American citizen.
By initialing here, I confirm that I am available and willing to travel to Washington, DC in June 2017 for one (1) week

The Session will be June 19th through June 23th

Two References are required (at least one referee must be an academic reference):

Name: / Name:
Title: / Title:
Department: / Department:
Institution: / Institution:
Phone number: / Phone number:
E-mail: / E-mail:

PLEASE COMPLETE THE QUESTIONS ON PAGE 2.

Please send your completed application by e-mail as an attachment to by

Wednesday, March 1, 2017.

Please include a CV or resume.

Increasing Diversity in Science and Technology Studies

2017 Undergraduate Student Fellowship Application – Page 2

Last Name / First Name / MI

Personal Narrative

1. What past, current or prospective social, political, cultural and/or ethical issues related to science and technology interest you and why? (250 words)

2. Please tell us about yourself, and describe your professional development and/or career goals. How will this program help you achieve those goals? (500 words)

3. What courses in or related to science and technology studies have you taken at college? Examples may include: bioethics, history of science, science policy, science and technology studies, public health, history of medicine.