Workshop Sign Up First Name * Last Name * Nursing License # * Home Address * City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip * Home Phone * Email Address (home/personal) * Name of Institution * Institution Address * City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip * Work Phone Work Email Address Have you had any previous genetics education? * - Select -NoYes, attended in-serviceYes, attended a workshopYes, completed an online CEUYes, took a genetics undergraduate courseOther What is your gender? * Male Female What is your ethnicity? * - Select -Hispanic/LatinoNon-Hispanic/Latino What is your race? * - Select -Asian/ Pacific IslanderBlack/ African AmericanNative American Indian or Alaskan NativeWhiteOther In what country were you born? * If not born in the US, at what age did you move to the US? * In what country did you receive your nursing education? * Clinical Area: * Pediatric Adult Both How would you describe your current nursing role? [Check all that apply] * Nurse educator or faculty member Registered nurse in clinical practice Advanced practice nurse in clinical practice Research Nurse Clinical researcher Laboratory researcher Other How long have you been a nurse? * Please choose the option that best describes your basic RN nursing education: * - Select -Nursing Diploma SchoolAssociate Degree in NursingBachelor Degree in NursingMaster’s DegreeOther What is your highest level of education achieved? * - Select -Nursing Diploma SchoolAssociate Degree in NursingBachelor Degree in NursingMaster’s DegreeDNPPhDOther MIT HAS PARKING AVAILABLE BY PERMIT ONLY IN ITS VISITOR PARKING LOT. WILL YOU NEED PARKING PERMITS? The workshop is taking place at The Koch Institute (500 Main Street, Building 76, Cambridge, MA), easily accessible via the Red Line (Kendall Square exit) or the #1 Bus. We have sessions planned at different sites on campus. Please indicate if you have any mobility issues that we should be aware of. How did you hear about this workshop? CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. What code is in the image? * Enter the characters shown in the image.