2018 Premedical Conference General Registration Form
Thank you for your interest in our conference. Please fill out all the required information to complete your registration.
Full name of High School, College, or University
High School Junior
High School Senior
Pre-med/ Pre-health advisor
American Indian or Alaskan Native
Hispanic or Latino
Phone Number (xxx) xxx-xxxx
Apt / Room Number
Do you have any special dietary needs?
If you require any special accommodations during the conference, please specify below:
Registration Payment and Deadline
The fee for general registration is $12. The deadline to submit your payment is March 30, 2018.
Please indicate which method of payment you will be using to pay your registration fee. If paying by debit or credit card, please download the payment form from the conference website.
Check (Make payable to UTMB Health)
Money Order (Make payable to UTMB Health)
Pre-med / Pre-Health Advisor (Registration fee waived)
Please mail check or money order to: UTMB Health, 301 University Blvd., Galveston, TX 77555-1308
If you have any questions or concerns, please contact LeTanya Neely at (409) 772-3763 or Email:
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