C34G Workshop Event Interest Form

Thank you for your interest in hosting a Cool Careers in Cybersecurity for Girls Workshop!
Please complete the form below.

First Name

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* 1. First Name

Last Name

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* 2. Last Name

Email Address

Please provide the email address you check most frequently and double check that you've entered it correctly!

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* 3. Email Address

Please provide the email address you check most frequently and double check that you've entered it correctly!

Second Email Address
Do you have a second email address…just in case

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* 4. Second Email Address
Do you have a second email address…just in case

Phone Number

Please provide the best phone number to reach you.

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* 5. Phone Number

Please provide the best phone number to reach you.

Note: If you have not already done so you may want to review the Host Organization Key Responsibilities found in the Event: To Host section of the website.

I am currently a(n)

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* 6. Note: If you have not already done so you may want to review the Host Organization Key Responsibilities found in the Event: To Host section of the website.

I am currently a(n)

Name and Location of School or Affiliated Organization
Ex: Current Employer, Organization, Library, School, or University

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* 7. Name and Location of School or Affiliated Organization
Ex: Current Employer, Organization, Library, School, or University

Which state would you like to host a C34G event in? (Select all that apply)

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* 8. Which state would you like to host a C34G event in? (Select all that apply)

What city?

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* 9. What city?

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