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2016 TRIP to YALE MEDICAL SCHOOL: REGISTRATION PAGE
Date: April 21st 2016
Dress appropriately (no hats, T-shirts etc.)
Last Name
Your answer
First Name:
Your answer
Banner ID#:
You must include the "@" symbol before your Banner ID! @XXXXXXXX Do NOT include NVCC.commnet etc.
Your answer
Phone:
Format: XXX-XXX-XXXX; NOTE: No parentheses around the area code
Your answer
Best Email:
Your answer
Requesting a seat on the bus (as long as seating is available)?
Required
Completed A&P II with at least a "C+" or are currently taking this semester?
Required
Who is your instructor?
(LAST NAME only)
Your answer
Are you currently enrolled in an Allied Health program?
If yes, which program?:
Your answer
LAST NAME
Emergency Contact
Your answer
FIRST NAME
Emergency Contact
Your answer
PHONE NUMBER #1
Emergency Contact; Use XXX-XXX-XXXX format (NO parentheses)
Your answer
PHONE NUMBER #2
Emergency Contact; use XXX-XXX-XXXX format (No parentheses)
Your answer
LUNCH HERO SELECTION (sorry, no modifications)
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