Health & Biomedical Sciences Summer Camp Registration

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Health & Biomedical Sciences Camp
Health & Biomedical Sciences Camp Application

Please complete the registration form below. You will receive a confirmation message upon successful application submission: if you do not receive a confirmation message, your application submission was not successful.

Applicant Information

First Name *

Last Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Student Email Address *

Student Cell Phone Number (to be used in case of emergency at the camp)

Date of Birth//

Gender *

Male
Female
Other/Prefer Not to Answer

Email address of high school teacher or guidance counselor who could serve as a reference (optional)

Parent(s)/Guardian Information

Parent/Guardian Name *

First

Last

Parent/Guardian Email Address *

Parent/Guardian Email Address 2 (optional)

Parent/Guardian Phone Number *

Parent/Guardian Phone Number 2 (optional)