IPRELS Application | ILSAMP | Chicago State University

IPRELS Application

If you see this don't fill out this input box.

*First Name:

*Last Name:

Suffix:

*Address:

*City:

*State:

*Zip Code:

*Email:

*Cell Phone Number:

*Bachelor's Degree in:

*When did you earn your degree?

*Were you an LSAMP Scholar as an undergraduate?

If yes, which Alliance?No

Which Alliance:

*Gender:

FemaleMaleOtherI would rather not say

*Race/ethnicity(s)

African American/BlackAsianHawaiian/Pacific IslanderHispanic/LatinxIndigenous/Native Alaskan/Native AmericanWhiteOther

*Citizenship:

U.S. CitizenU.S. Permanent ResidentOther

If other

Choice of Research Mentor/Research Projects:(Make a choice, 1-18, based on the options listed above)

*First Choice:

*Second Choice:

*Third Choice:

*Do you have a need that would require special accommodation?

If yesNo

If yes, please briefly explain:

*Do we have your permission to use your photos and/or video footage(s)?

YesNo

If yes, provide your full name.

Your full name:

*HEALTH AND SAFETY: I understand that all prevailing state and local mandates on COVID-19 may apply at my chosen research site/environment.

YesNo

ILSAMP

9501 S. King Drive Chicago, IL 60628

(773) 995-2000