1. Name*
2. E-mail Address*
3. Primary Telephone*
4. Alternate Telephone
5. Current Position* -- Select One -- Graduate Student Post-Doc Genetic Counselor
6. Department*
7. University* -- Select One -- Duke Univ North Carolina State Univ Univ of North Carolina at Chapel Hill Wake Forest Univ NIEHS North Carolina Central Univ North Carolina A&T State Univ UNC - Charlotte Other- Indicate in Additional Comment

*How much time would you be willing to volunteer on Friday, April 23rd? (including travel time)
AM PM
All Day No Preference

*Are you available any additional days that week, April 19-22nd? (Please indicate what day in Additional Comment box, located at the end of the application.)
Yes No

*Will you have access to a car on Friday, April 23rd?
Yes No

 

*Are you interested in meeting with a small group of students to discuss biomedical science careers?
Yes No

 

*Do you have friends or family in North Carolina that you would be willing to stay with prior to DNA Day. Then indicate their location below. This will allow us schedule visits to more remote areas of North Carolina.
Yes No If Yes, Location:

 

If you have a partner preference, please provide the name of your preferred partner. (Make sure volunteer information is compatible with your partner’s information)

Below are a list of DNA Day modules for 2010. Check only modules that you would NOT be comfortable teaching.

(For a module description, click on the module's name)

1. Pharmacogenomics Module
2. Genes and Diseases Module
3. Cystic Fibrosis Module
4. Farming and Biotech Module
5. Forensics Module
6. Immunology Module

If you require special accommodations please indicate so below. Also, address any additional comments you have: