Women and Math Registration Name (first and last):


Address:


City:


State:
Zip Code:

Phone:


E-Mail:


Emergency Contact:
Relationship:

Emergency Contact Phone Number:


High School:
Teacher:

Current Math Course:


High School Class (i.e. "sophomore") or college:



Choice of workshop topic area (Please rank your top 5 choices: 1,2,3,4,5):

Architecture:

1 2 3 4 5


Health Services:

1 2 3 4 5


Cyber Security:

1 2 3 4 5


Materials Engineering:

1 2 3 4 5


Math Modeling/Sims:

1 2 3 4 5


Financial Services:

1 2 3 4 5


Civil Engineering:

1 2 3 4 5


Computer Science/IT:

1 2 3 4 5


Pharmacy:

1 2 3 4 5


Meteorology:

1 2 3 4 5


Chiropractic/Radiology:

1 2 3 4 5


Physics:

1 2 3 4 5


Astrophysics:

1 2 3 4 5


Mathematics:

1 2 3 4 5


Veterinary Medicine:

1 2 3 4 5


Continental breakfast and lunch will be provided. Register by October 11 and be automatically entered in a drawing to win a $50 gift certificate.