Scholarship Application Contact Information Name: Street Address: City, State, ZIP Code: Home Phone: Work Phone: E-Mail Address: Class Information Which class would you like to attend? Class name:____________________________________________ Dates:______________________________ Background Please tell us if any of the following apply to you: _____ K-12 Teacher _____ High School Student ____ Undergraduate Student _____ Graduate Student Volunteering To give back to BUGSS, are you willing and able to volunteer 5-10 hours of time? (This could include work on a member project or general help around the lab) ____ YES ____ NO Previous involvement with BUGSS Summarize your previous experience with the BUGSS organization, including any classes that you have previously attended. Future involvement with BUGSS The BUGSS class scholarship provides a three month BUGSS membership which entitles you not only to attend courses for free (courses typically run over a 1-2 month period), but also to use the lab space. If given a scholarship, do you have ideas for how you might use that additional membership time? Are there projects that you are interested in pursuing at BUGSS? Please describe below. Please sign below Name (printed) __________________________________________________________________________ Signature __________________________________________________________________________ Date __________________________________________________________________________ Our Policy It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability. Thank you for completing this application form and for your interest in attending a BUGSS course!