Counselor Colloquium Registration

Registration form

(all fields are required)

1. Please tell us about yourself

   Salutation:	Dr. Mr. Mrs. Ms.
   First Name:
   Last Name:
   Gender:	Male Female
   Job Title:
   Email Address:

2. Provide your home address (Confirmation details will be mailed to your home)

   Street 1:
   Street 2:
   City:
   State:	AA AE AP AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH MP OK OR PA PW PR RI SC SD TN TX UT VA VI VT WA WV WI WY XX	Zip Code:
   Home Phone:	(including area code)

3. Provide information about your school

   School Name:
   Street 1:
   Street 2:
   City:
   State:	AA AE AP AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH MP OK OR PA PW PR RI SC SD TN TX UT VA VI VT WA WV WI WY XX	Zip Code:
   School Phone:	(including area code)
   School Fax:	(including area code)

4. Have you previously attended the Counselor Colloquium at UT Austin?

   Yes
   No
   

5. Do you need overnight accommodations at the San Jacinto Residence Hall? (all rooms are non-smoking and double occupancy)

   Yes
   No
   

6. Roommate Request:

   First Name:
   Last Name:

7. Will you be carpooling to the Colloquium?

   Yes
   No
   

   If yes, with whom:

   First Name:
   Last Name:

8. Do you have any special requests, dietary needs, or other accommodations for your stay?

   Special needs/requests details:
   

9. Please indicate your T-shirt size:

   Small
   Medium
   Large
   X Large
   XX Large
   

10. Please select 2 of the following tours:

    Moncrief-Neuhaus Athletic Center and Football Suites
    UT President's Office
    LBJ Library & Museum (self-guided tour)
    Harry Ransom Center
    Texas Memorial Museum (offered only during the first tour)
    Blanton Museum of Art (offered only during the second tour)
    

11. Please select 3 colleges/schools you wish to visit during the Colloquium:

    Business
    Communications
    Education
    Engineering
    Fine Arts
    Geosciences
    Liberal Arts
    Natural Sciences
    Nursing
    Pharmacy
    Social Work
    Undergraduate Studies
    

12. What topics are you interested in learning more about during the Counselor Colloquium?

    Topics of interest: