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.

* 1. First Name

* 2. Last Name

* 3. Email Address

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

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

* 5. Phone Number

Please provide the best phone number to reach you.

* 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)

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

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

* 9. What city?