Name* Best email address to contact you at* Best phone number to reach you at* Current Street Address City State Zip Major(s)/Area(s) of study School Year Graduated Current position/location: Do you plan to be in the East Central Illinois region anytime between July 2012 and February 2013? If so, please detail: If so, would you be willing to be interviewed on tape for a promotional video supporting the Christie Foundation and its programs? Yes No In 3-4 sentences, describe how you choose this field of study and why you are passionate about it. In 3 sentences, describe where you grew up and tell us a bit about your family. In 3 sentences, describe your current studies and schooling (i.e., what does a typical day look like, what classes/labs do you have, etc.). In 3-4 sentences, describe your profession and work once you graduate: where do you envision yourself, what are you doing, and whom are you helping? Do you have plans to engage with any non-profit or NGO-based organizations such as Doctors Without Borders or American Red Cross? If so, please tell us what motivates you to do this, where you’d like to go, and what you envision yourself doing. Tell us a little more about you outside of your studies: what are your hobbies and interests? Spam prevention, leave blank
