2024 Networking Reception for Black Students, Housestaff and Faculty

First Name*

Last Name*

Preferred Nametag Name (e.g., John Smith, Jr., Beth Jones)*

Email*

Cell Phone*

Affiliation*

Expected Degree Year

Department

Title

Will you be bringing a guest?*

Name of Guest

Does anyone in your party have allergies/dietary restrictions?*

Please describe allergies/dietary restrictions here.

Does anyone in your party have any mobility restrictions?*

Please describe mobility restrictions or required accommodations here.

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