2021 59th Annual QCESC STEM Celebration Pre-Registration
The event is on Thursday, February 25, 2021 and will be live-streamed virtually. The event will be virtual this year, and we're recommending a $10 donation per household.

Event Link for youtube livestream:
https://youtu.be/GmaJb5lak4c

See our event website for more information: https://qcesc.org/stem-celebration/

Everyone, including students, are cordially invited to attend this annual premier event to celebrate, network and showcase the great Science, Technology, Engineering and Math (STEM) Professionals and STEM educators in the Quad Cities region.   The event is being held during Engineer Week (E-week).  

You can register up to 8 people with this form.  You must fill out all of the mandatory fields as indicated by a * symbol at the end of the field name (i.e. Name *) for the form to be saved and submitted.  If you properly fill out the form and submit, you should see a message that says "Thanks - Your response has been recorded and e-mailed to the QCESC. If you don't see this message, you need to update or add missing information which will be highlighted on the form in red color.

After successfully submitting your registration, you will be automatically linked to a site to pay on-line using a credit card or PayPal: https://qcesc.org/stem-celebration-payment-page/.  Since the event is virtual this year, we're recommending a $10 donation per household. A confirmation of what you submitted will be e-mailed back to you automatically after you successful submit the form.  

The information you submit will only be used by the QCESC and will not be redistributed or sold.

If you have questions or need further Information, please contact one of our officers: http://qcesc.org/board-of-directors/
Sign in to Google to save your progress. Learn more
Email *
Contact Information for Person Submitting Registration Form
Your First Name *
(example John)
Your Last Name *
(Example Smith)
Phone Number *
(Form XXX-XXX-XXXX) Will only be used if we need contact you and are unable to by e-mail.
Total Number of People You Are Registering with this Form *
Should be between 1-8, Submit Another Form if More than 8
Comments or Questions
If you have any additional comments or questions, please add them to the comment box below including any special dietary restrictions.
Registration - Person 1
Fill out information for each person attending, up to 8 total
First Name - Person 1 *
Last Name - Person 1 *
Society Currently Belong To, If Any (IEEE, SAME, SWE, Etc.)  - Person 1
Note:  Not required to belong to a society to attend Celebration
Employer or School If Full-time Student - Person 1
Registration - Person 2
First Name - Person 2
Last Name - Person 2
Society Currently Belong To, If Any (IEEE, SAME, SWE, Etc.)  - Person 2
Note:  Not required to belong to a society to attend Celebration
Employer or School If Full-time Student - Person 2
Registration - Person 3
First Name - Person 3
Last Name - Person 3
Society Currently Belong To, If Any (IEEE, SAME, SWE, Etc.)  - Person 3
Note:  Not required to belong to a society to attend Celebration
Employer or School If Full-time Student - Person 3
Registration - Person 4
First Name - Person 4
Last Name - Person 4
Society Currently Belong To, If Any (IEEE, SAME, SWE, Etc.)  - Person 4
Note:  Not required to belong to a society to attend Celebration
Employer or School If Full-time Student - Person 4
Registration - Person 5
First Name - Person 5
Last Name - Person 5
Society Currently Belong To, If Any (IEEE, SAME, SWE, Etc.)  - Person 5
Note:  Not required to belong to a society to attend Celebration
Employer or School If Full-time Student - Person 5
Registration - Person 6
First Name - Person 6
Last Name - Person 6
Society Currently Belong To, If Any (IEEE, SAME, SWE, Etc.)  - Person 6
Note:  Not required to belong to a society to attend Celebration
Employer or School If Full-time Student - Person 6
Registration - Person 7
First Name - Person 7
Last Name - Person 7
Society Currently Belong To, If Any (IEEE, SAME, SWE, Etc.)  - Person 7
Note:  Not required to belong to a society to attend Celebration
Employer or School If Full-time Student - Person 7
Registration - Person 8
First Name - Person 8
Last Name - Person 8
Society Currently Belong To, If Any (IEEE, SAME, SWE, Etc.)  - Person 8
Note:  Not required to belong to a society to attend Celebration
Employer or School If Full-time Student - Person 8
End of Form
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms