University Visit Program

Student Application

Please complete application in its entirety, save as PDF and email to: .

All application materials must be received at least three weeks before proposed visit date.

Part I: Applicant Information

Last Name: ______First Name: ______Middle: ______

Current Institution (if applicable): ______City, St: ______

Email Address: ______Phone Number: ______

Are you a participantof any of the following?:

☐McNair Scholar☐Mellon Mayes Undergraduate Fellow☐ Student Support Services (SSS)

☐LSAMP☐MARC Scholar☐Other:______

Part II: Demographic Information (for Diversity Office tracking and reporting purposes)

Gender: ☐Female☐Male☐Self identify as: ______

Race/ethnicity: Select all that apply:

☐ African American/Black☐Latina/o☐ White☐ American Indian/Alaskan Native☐ Asian

☐ Native Hawaiian/Pacific Islander☐ Other: ______

Citizenship:☐ U.S. Citizen☐ Permanent Resident

Are you a first-generation college student?:☐Yes☐No

Part III: Prospective Graduate Programat University of Utah

Name of Graduate Program: ______Degree (e.g. M.S., Ph.D.): ______

Department: ______College: ______

Prospective Faculty Advisor: ______

Part IV: Optional Meetings(*NEW*): To maximize your visit and create the best experience possible, the Graduate School Diversity Office is happy to coordinate additional meetings during your visit to the University of Utah. Please note, this indicates an effort will be made to schedule a meeting with someone, although availability of a representative cannot be guaranteed.

Directions: Please select which groups you would like to meet by indicating a “1” extremely interested

through “5” interestedin each respective box. Only selectoptions that you are interested in.

☐McNair Scholar alumni☐African American Doctoral Scholars Initiative

☐Black Graduate Student Association☐Assoc. of American Indian Graduate Students

☐Women of Color Academics☐Center for Childcare & Family Resources☐SACNAS

☐Xicana/o Graduate Council☐Muxerista Mothers☐Minority Law Caucus

☐Graduate chapter of racial/ethnic fraternities or sororities ( indicate fraternity/sorority of interest: ______

Part V: Essay

Please address the following prompt as honest as you can. Your essay is limited to a maximum of 500 words and must be double-spaced.

Pleasedescribe how you identify as a member of a historically underrepresented population, ways in which you haveworked with or servedhistorically underrepresented groups in the U.S., and how an in-person visit will be beneficial to you.

How did you hear about the sUniversity Visit Program?

 Email Graduate School Diversity Office webpage  Professor (name): ______

Other: ______

Please read and sign the following statement:

I hereby certify that the above information is true and correct to the best of my knowledge. If selected for a UVP travel award, Iagree to respond to an email from the Diversity Office to complete a short follow-up evaluation of my visit.

Signature: ______Date: ______