Chapters Creation Form If you are interested in applying to launch a chapter on your campus/in your community, please complete and submit the form below! We will reach out to those selected to set up a time to discuss next steps. Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Gender*MaleFemaleNon-BinaryPrefer Not to AnswerDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Preferred Phone* Home Cell Work Primary Phone*Email* UMR Chapters*Do you hope to start a college/university chapter or a community chapter?College/University ChapterCommunity Chapter*What academic institution or community would your UMR chapter represent?*Are you a current student/graduate of the academic institution you selected OR a resident of the community you selected?YesNo*Do you live in close enough proximity to the academic institution/community you selected to consistently lead meetings and events in-person?YesNo*If applicable, are you in good academic and disciplinary standard with your academic institution?YesNoNot ApplicableAcademic Year*What is your class standing as of the 2021 spring semester?FreshmanSophomoreJuniorSenior5th YearGraduate StudentNot ApplicableExpected Graduation*Spring 2021Fall 2021Spring 2022Fall 2022Spring 2023Fall 2023Spring 2024OtherNot applicableAreas of Study(You can choose multiple studies by holding the control/command button when selecting)HistoryLanguages and LinguisticsLiteraturePerforming ArtsPhilosophyReligionVisual ArtsAnthropologyArchaeologyArea StudiesCultural & Ethnic StudiesEconomicsGender & Sexuality StudiesGeographyPolitical SciencePsychologySociologySpace SciencesEarth SciencesLife SciencesChemistryPhysicsComputer SciencesLogicMathematicsStatisticsSystems ScienceAgricultureArchitecture & DesignBusinessDivinityEducationEngineeringEnvironmental Studies & ForestryFamily & Consumer ScienceHealth SciencesHuman Physical Performance & RecreationJournalism, Media Studies, & CommunicationLawLibrary & Museum StudiesMilitary SciencesPublic AdministrationSocial WorkTransportationOtherReferral Source*How did you hear about our organization and our chapters program? UMR Website Third-Party Website Social Media Fundraiser/Campaign/Event Word-of-Mouth (Friend, Family, Colleague) Mailer Advertisement Other