2019 Summer Camp Application
Select preferred camp date *
Camper Information
First Name: *
Your answer
Last Name: *
Your answer
Home Address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip: *
Your answer
County:
Your answer
Birthdate: *
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DD
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Phone: *
Your answer
E-mail Address: *
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T-shirt Size:
Scrub top size:
Scrub bottom size:
Do you have any allergies or food intolerances?
Your answer
Parent and/or Legal Guardian Information
Name: *
Your answer
Phone: *
Your answer
Relationship to camper: *
Your answer
Name:
Your answer
Phone:
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Relationship to camper:
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Education Information
High School Name: *
Your answer
High School Graduation Year: *
Your answer
High School GPA to date:
Your answer
Name of Guidance Counselor:
Your answer
Phone:
Your answer
ACT Score:
Your answer
Other information
How did you hear about Health Career Camp? *
What area of health care are you interested in? *
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