Registration for November 16th Workshop in Salem

Parent's Name (or accompanying adult's name) *

First

Last

Parent's Email (or accompanying adult's email) *

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Daughter *

First

Last

Additional Daughter

First

Last

Additional Daughter

First

Last

Grade (check all that apply) *

3rd
4th
5th

STEM Like a Girl offers scholarships for families who would like to attend but need financial assistance to cover the workshop cost. If you would like a scholarship, please select "Workshop Scholarship" during the checkout process on the payment page and workshop costs will be waived.

Yes, I’d like to receive a scholarship for my daughter(s)

Have you previously attended one of our Parent-Daughter Workshops? *

Yes, we have previously attended a workshop
No, this is our first one

How did you hear about us? *

What school does your daughter(s) attend? (optional)

What is your race? (optional, more than one category may be selected)

Are you Hispanic, Latina, or of Spanish origin? (optional)