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2004 Summer SALSA Security Workshop Registration

21-22 July 2004
Columbus, OH

*Fields marked with an asterisk are required.

First Name*
Last Name*
Organization*
Email*
Telephone*
Meal Preference*
Allergies
Special Needs


Any protected health information (PHI) provided with this registration will be safeguarded by Internet2 from unauthorized disclosure. With this registration, Internet2 is authorized to use this PHI for your special needs or emergency situations during this event only. Your PHI will be discarded from our records at the end of this event. If you wish to file a complaint of privacy violations, please contact privacyofficer@internet2.edu or file the complaint directly with the U.S. Secretary of Health and Human Services at <http://www.cms.hhs.gov>.