Hack-A-Thon Application | Von Allmen Center for Entrepreneurship

First Name *

Last Name *

Middle Name or Initial

Address 1 *

Address 2

City *

State *

ZIP code *

Address *

Phone Number *

Email Address *

Are you a citizen of the United States? *

Are you authorized to work in the U.S.? *

Hack – Tracks Selection *

Hack – Tracks Selection Other...

Team members I want to work with

If you don't have any team members, on Friday, September 18th you will be assigned to a team by your track.

Name

Email Address

Name

Email Address

Name

Email Address

I certify that my answers are true and complete to the best of my knowledge. I understand that by submitting this application, there is no guarantee of winning any funding. If this application leads to monetary awards, I understand that false or misleading information in my application may result in forfeiture of funds. I the undersigned, hereby authorize the University of Kentucky to photograph me, take motion pictures of me, take video footage of me, and/or make electronic sound recordings of me (herein referred to as photographic or electronic reproductions). I authorize the use of any such photographic or electronic reproductions of me for any purpose, including, but not limited to educational and other public media as may be deemed appropriate by the University of Kentucky (I understand that I may be identifiable from such photographic or electronic reproduction) *

Yes

Signature (Initials) *