Qualtrics Survey | Qualtrics Experience Management

Requirements and Qualifications
1. Must be either: a) a high school junior or senior or b) a college freshman or sophomore.
2. Minors (under age 18) must have a parent, guardian, or older sibling drop them off and pick them up from the event.
3. Have an interest in personal and career development.
4. Have an interest or desire to meet professionals in the field of neurology.
5. Have an interest or desire to participate in hands on activities.
6. Keep an open mind to different careers, cultures, and backgrounds.
7. Understand that DNA is an opportunity for me to learn and grow as a person. I will act like a mature and professional student at all times during the event and represent my school with pride.
8. Finally, and most importantly, HAVE LOTS OF FUN!!

Parent or Guardian Notification (For Students Under Age 18): I understand my child’s desire to participate in DNA at UCI at I give him/her/them permission to apply to the program. Please type name below:

Parent or Guardian Notification: Please Sign Below

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General Information

Last Name

First Name

Street Address

City, State, Zip

E-Mail

Alternate E-Mail

Home Phone Number

Cell Phone Number

School

Grade/Year

Birthday (MM/DD/YYYY)

Gender (Male, Female, Non-Binary, Decline to Answer)

Food Allergies or Special Dietary Needs

Emergency Contact (Please Provide Two Names)

Last Name

First Name

Relationship

Phone Number

Last Name

First Name

Relationship

Phone Number

Do you have any family members who work in the medical field? If yes, please describe.

Medical and Disability Information

Please list current medical conditions or disabilities that may impact participation in the event

Do you require special accommodations? If yes, please describe

How did you hear about DNA?

Why do you want to attend DNA and what do you hope to gain? 1200 Character Max

Please describe a challenge or obstacle you overcame in your lifetime, and describe how doing so has led to personal growth. 1200 Character Max

Please describe your career goals. For college students, please describe your current area of study as well. 1200 Character Max

Please describe up to 3 of your extracurricular activities (sports, clubs, volunteer work, part time jobs, etc.). Please include the dates and a description of your involvement. 1200 Character Max

I certify that the above information is true and correct and has been completed to the best of my ability.

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Parent or Guardian Signature (For Students Under age 18)

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If you are accepted to the DNA program, you (or your parent or guardian for students under age 18) will be required to sign a UCI Waiver Agreement. If you have additional questions, please contact: IdeasCommittee@hs.uci.edu