The following survey is designed to allow you to submit the relevant project information directly to BLUElab's executive committee.

IDENTIFICATION

Your Name:

Address:

City:

State/Province:

Country:

Zip/Postal Code:

Phone:

Fax:

Email:

Community:

Your Role:

Project Title:

PROJECT DESCRIPTION

1. Describe the problem, project, or community need.


2. Describe the region the community is in.


3. Please provide a brief background of the problem or need.

PROJECT CHECKLIST

Do you live in the community described in this application?
Yes
No
Are you originally from the community described in this application?
Yes
No
Will you be living in the community for at least the next year?
Yes
No
Are you capable of being available to consult with an interdisciplinary student group to develop solutions to the need faced in this community?
Yes
No
Do you anticipate that students will need to travel to your location?
Yes
No