Registration for Science180 Academy Program

Name*

Your address

City

State

Zip code / postal code

Country*

Phone

Your Website* (e.g. https://Israel120.com) Please include “https://” or “http://” in your website URL.

Mission Statement / Purpose / Objective

Email*

Date you are targeting

Length / Duration of the program

Is it live or virtual or tape?

Who is the Science180 Academy targeting? (Describe the attendees or participants)

What types of topics are you interested in?

Science180 Academy Program You are Interested in

Your Scientific background (Multi select)

Philosophical / Religious background (Multi select)

Freethinkers? (Multi select)

Your Budget (how much you will pay us) for this Science180 Academy Program?*