Diversity Travel Fellowship

Name*

First Last

Affiliation*

Level of Study*

Year of Study*

e.g. second year

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

Have you presented at BUCLD previously?*

Have you received a BUCLD Student Travel Award previously?*

Gender

You may further specify your gender identity if you choose.

Are you the first generation in your family to attend and/or graduate from a 4-year college?*

Race/Ethnicity:

If other, please specify:

Do you have a disability?

If yes, please describe your disability:

Total Estimated Expenses:*

Note: Receipts may be requested for disbursement so please provide a realistic estimate. All air travel must be with US carriers.

Please detail the expenses that you will incur during conference participation.*

Comments

Please provide any additional comments regarding your need for travel support (e.g. itemization of expenses, etc.)