DIMACS :: Application for Reconnect 2023: Risk Assessment

First name *

Last name *

Title

Organization *

Department

Street address *

City *

State *

Postal code *

Country (if not USA)

Primary phone *

Alternate phone

Email address *

Citizenship

US citizen

Dual citizen

Non-US citizen

Gender

Male

Female

Other

Your undergraduate institution(s) *

Degree year *

Major *

Minor

List any graduate degrees on a separate line.
Include: degree, institution, department, year of degree.

List any certifications on a separate line.

Include certification & year.

Why do you want to attend the Reconnect Program?

How do you think you will benefit from it? *

What courses have you taught in the last two years?

What courses do you expect to teach in the next academic year?

What is your mathematics background, if any? *

What is your computer science background, if any? *

When did you last do research and what was it about? *

Will you have an opportunity to use ideas from Reconnect 2023

in one or more of the following activities?*
(Check all that apply) *

In a course

In undergraduate research projects

In a departmental or interdisciplinary seminar on my campus

In a government or industry research project

Other

If you checked "other", please describe

Do you agree to attend the entire program? *

Yes

No

Will you complete written classroom materials by January 2024? *

Yes

No

If you need travel support, indicate the amount

Please explain in a few sentences
why you need the support,
what other sources of support you might have,
and how you would cover the transportation costs without this award.

Please indicate your dietary restrictions or other special needs *

Please type the letters and numbers shown in the image.

Click the image to see another captcha.

Application for Reconnect 2023: Risk Assessment

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