First Name:  *

Last Name:  *

Email Address:  *

Phone number (put N/A if not available):  *

University or Organization you are affiliated with:  *

City where your university or organization is located:  *

State (2-letter abbreviation) where your university or organization is located:  *

In 100 words or less state why your organization or school would like to join this video conference.  *

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