Scrubs Camp Registration Personal InformationStudent Name *Home Address *CityState/ProvinceZIP / Postal CodeEmail Address *For confirmation/acceptance letter.Date of Birth *Ethnicity *African AmericanAsianCaucasian/WhiteHispanic/LatinoNative AmericanOtherName of school presently attending:Current grade in school *Please select one9th10th11th12thPlease select which session you would like to attend. *Morning (8:00 AM - 11:15 AM)Afternoon (12:00 AM - 3:00 PM)All Day (8:00 AM - 3:00 PM & lunch break at 11:15 AM to 12:00 PM) Have you previously attended a Scrubs Camp? *YesNoIf you were referred by a friend, please put their name!Parental/Guardian InformationName of Parent/Guardian *Home Address *City *State/Province *ZIP / Postal Code *Daytime Phone Number *Evening Phone Number *Parent's Email Address *Career InterestAre you interested in a healthcare career? *YesNoUnsureWhat healthcare career(s) are you interested in pursuing?Please complete the document below and return to Northeast SD AHEC by mail or email: info@nesdahec.orgSubmit Registration! Share this:EmailPrintLinkedInFacebookTwitterLike this:Like Loading...
