Coalition to Diversify Computing

CDC Conference Support
Student Application to Attend
Technical Conferences in CSE

If you wish to receive conference support, please complete and submit the following information. We recommend you print this form, gather information, and prepare your response prior to filling it out. Incomplete applications will not be considered. Applicants must be US citizens or permanent residents. Support will be limited to $1,000 per applicant.
_____________________________________________________________________________________

Full Name:

Address Line1:

Address Line2:

City:

State:

Zip:

Home Phone Number

Work Phone Number (if applicable):

E-mail Address:

Fax Number
(if applicable):

College or University:

Degree currently pursuing:

Major:

Minor
(if applicable):

GPA, overall:

GPA in Major:

Anticipated Date of Graduation:

Citizenship:

Post-Graduation Plans:

Research Experience(s):

Publications, if any:

Presentations, if any:

Posters, if any:

Courses that you have taken or experiences that you have had that you believe have prepared you to appreciate and gain from attending the conference designated below:

___________________________________________________________________

CONFERENCE INFORMATION:

Conference Name:

Dates:

to

Conference URL:

Location:

Preregistration Deadline:

Are you presenting a paper at the conference?

If yes, please list the title and author(s):

Are you presenting a poster at the conference?

If yes, please list the title and author(s):

Are you a student volunteer at the conference?

If yes, what benefits do you receive for being a volunteer?

Conferences you have attended in the past:

Essay:
In essay format, describe how you believe you will benefit from attending the designated conference (cut and paste from a program that will allow you to run spell check).

___________________________________________________________________

EXPENSE INFORMATION:

Conference Registration Fee:
Indicate schedule of fees, e.g., preregistration fee and registration fee on site

Registration Information:
e.g., registration contact person, address to which registration information and fee should be sent

Air Travel:
In addition to estimated cost, indicate airports of departure and arrival, airline and flight information on which quote was based

Local Travel:
e.g., cost of shuttles to and from airport

Hotel:
Indicate the duration of hotel stay, the quoted cost per night, and hotel that quoted the rates—including contact information

Meals:
Do not include meals supplied by the conference

___________________________________________________________________________

MENTOR INFORMATION:

Please discuss this application with your mentor, i.e., the person who will attend the conference with you, and supply the following information regarding your mentor. Your mentor needs to fill out the form at: http://www.ncsa.uiuc.edu/Outreach/CDC/conf-support/mentorquery.html

Name:

Title:

College, University or other Institution:

Address Line1:

Address Line2:

City:

State:

Zip:

Phone Number:

Fax Number:

E-mail Address:

______________________________________________________________________________________

PEER INFORMATION:

In some cases, it may be advantageous if two or three students attend the same conference, perhaps from the same institution with a common mentor. If another student(s) with whom you are familiar is planning on attending the conference designated above, supply the following information regarding the other student(s).

Student 1:

Name:

Address Line1:

Address Line2:

City, State, Zip:

Phone Number:

Fax Number:

E-mail Address:

College or University:

Degree currently pursuing:

Mentor Name:

Major:

Minor (if applicable):

Is this student submitting an application for CDC support?

Student 2:

Name:

Address Line1:

Address Line2:

City, State, Zip:

Phone Number:

Fax Number:

E-mail Address:

College or University:

Degree currently pursuing:

Mentor Name:

Major:

Minor (if applicable):

Is this student submitting an application for CDC support?

If you wish to receive conference support, please complete and submit the following information. We recommend you print this form, gather information, and prepare your response prior to filling it out. Incomplete applications will not be considered. Applicants must be US citizens or permanent residents. Support will be limited to $1,000 per applicant. _____________________________________________________________________________________
Full Name:
Address Line1:
Address Line2:
City:		State:		Zip:
Home Phone Number		Work Phone Number (if applicable):
E-mail Address:			Fax Number (if applicable):
College or University:			Degree currently pursuing:
Major:		Minor (if applicable):
GPA, overall:		GPA in Major:
Anticipated Date of Graduation:
Citizenship:
Post-Graduation Plans:
Research Experience(s):
Publications, if any:
Presentations, if any:
Posters, if any:
Courses that you have taken or experiences that you have had that you believe have prepared you to appreciate and gain from attending the conference designated below:
___________________________________________________________________ CONFERENCE INFORMATION:


Conference Name:				Dates:	to
Conference URL:
Location:			Preregistration Deadline:
Are you presenting a paper at the conference?
If yes, please list the title and author(s):
Are you presenting a poster at the conference?
If yes, please list the title and author(s):
Are you a student volunteer at the conference?
If yes, what benefits do you receive for being a volunteer?
Conferences you have attended in the past:
Essay:		In essay format, describe how you believe you will benefit from attending the designated conference (cut and paste from a program that will allow you to run spell check).
___________________________________________________________________ EXPENSE INFORMATION:


Conference Registration Fee:	Indicate schedule of fees, e.g., preregistration fee and registration fee on site
Registration Information:	e.g., registration contact person, address to which registration information and fee should be sent
Air Travel:	In addition to estimated cost, indicate airports of departure and arrival, airline and flight information on which quote was based
Local Travel:	e.g., cost of shuttles to and from airport
Hotel:	Indicate the duration of hotel stay, the quoted cost per night, and hotel that quoted the rates—including contact information
Meals:	Do not include meals supplied by the conference

___________________________________________________________________________ MENTOR INFORMATION:


Please discuss this application with your mentor, i.e., the person who will attend the conference with you, and supply the following information regarding your mentor. Your mentor needs to fill out the form at: http://www.ncsa.uiuc.edu/Outreach/CDC/conf-support/mentorquery.html
Name:
Title:
College, University or other Institution:
Address Line1:
Address Line2:
City:		State:		Zip:
Phone Number:		Fax Number:
E-mail Address:
______________________________________________________________________________________ PEER INFORMATION:


In some cases, it may be advantageous if two or three students attend the same conference, perhaps from the same institution with a common mentor. If another student(s) with whom you are familiar is planning on attending the conference designated above, supply the following information regarding the other student(s).
Student 1:
Name:
Address Line1:
Address Line2:
City, State, Zip:
Phone Number:		Fax Number:
E-mail Address:
College or University:			Degree currently pursuing:
Mentor Name:
Major:		Minor (if applicable):
Is this student submitting an application for CDC support?
Student 2:
Name:
Address Line1:
Address Line2:
City, State, Zip:
Phone Number:		Fax Number:
E-mail Address:
College or University:			Degree currently pursuing:
Mentor Name:
Major:		Minor (if applicable):
Is this student submitting an application for CDC support?