COVID-19 Information

DICE Office Request for Student Conference Travel Funding Form

Students should submit membership and conference travel requests at least 30 days prior to travel.

Entries marked with * are required.

First Name*:

Last Name*:

Email*:

Phone*:

Program*:

If Other, please describe your program:

If MD, please choose your current year:

Please enter the address where you'd like your reimbursement check sent*:

Please describe why you consider yourself disadvantaged*:

Please describe how the conference supports diversity efforts*:

Please attach a description (website, flyer, etc.) of the conference you plan to attend*:

PDF files only