PCPR - Fall Symposium - Registration

1
I understand this is an virtual event.* This field is required.
YESNO
2
Are you a Member of PCPR?* This field is required.
YESNO
3
Name* This field is required.
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First Name
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4
Phone Number* This field is required.
Please enter a valid phone number.
5
Email* This field is required.
example@example.com
6
Mailing Street Address Example: 123 Main Street (Do not include city, state and zip code)
7
City* This field is required.
8
State* This field is required.
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Zip Code* This field is required.
10
Organization* This field is required.
11
Job Title* This field is required.
12
I would like to be an exhibitor at this event. Please reserve my 6 foot table.Exhibitor Registration is a $100 donation to PCPR.
YESNO
13
I would like to have a FREE professional headshot taken for my use at this event.This is a FREE Service for Members & Guests Attending This Event.
YESNO
14
What workforce group are you part of?* This field is required.
Please Select
Please Select
Traditionalists or Silent Generation: Born 1945 and before
Baby Boomers: Born 1946 – 1964
Generation X: Born 1965 – 1976
Millennials or Gen Y: Born 1977 – 1995
Gen Z, iGen, or Centennials: Born 1996 –
15
How many years have you worked, volunteered and/or advocated in college access and success?* This field is required.
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Please Select
0 - 2
3-5
6 - 10
11 or more
16
How long have you been affiliated with the Philadelphia College Prep Roundtable?* This field is required.
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Please Select
0 - 2
3-5
6 - 10
11 or more
17
Which area would you say is your primary area with college access and success?Check All That Apply
College Access and Success Programs
Higher Education
K-12
Parent and Families
Community Based Organizations (other than college access)
Faith Based Organizations
Civic and Government Agencies
Out of School Time Programs
Mentoring Programs
Business Community
Foundations and Research Organizations
Advocacy and Policy Makers
Other
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Monthly Network Meeting* This field is required.Click on Meeting Time & Date Below
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Date
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Day
Year
20
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