2019 OUCOP Future PharmeRx Preview Day
Wait List Registration

OUCOP Future PharmeRx Preview Day

The OUCOP Future PharmeRx Preview Day will be on Saturday, February 23, 2019 beginning at 9:00 am and ending by 2:30 pm that day. This event is FREE. For proper planning for supplies and materials, please register no later than Friday, February 8, 2019. Registration is limited to the first 75 students and is open to grades 6-12.

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* 1. Please complete all fields below.

First Name *

Last Name *

City/Town:

Email Address: *

Phone Number: *

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* 2. What is your age group?

Middle School

High School

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* 3. What grade are you in?

6th Grade

7th Grade

8th Grade

9th Grade

10th Grade

11th Grade

12th Grade

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* 4. If you are currently in school, please list your school and location.

School Name

City

State

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* 5. Please list your emergency contact.

First Name

Last Name

Address

City/Town

State/Province

ZIP/Postal Code

Relationship to You (e.g. mother, father, etc.)

Email Address

Cell Phone Number

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* 6. Please list any allergies or dietary restrictions you or your guests may have.

Allergies (e.g. latex, peanuts, etc.)

Dietary Restrictions (e.g. vegetarian, diabetic, etc.)

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* 7. Will your parents/guardian or an adult be attending with you that day?

I will be attending alone.

My parent(s) will be attending.

My guardian(s) will be attending.

An adult other than my parents/guardian will be attending.

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* 8. How many people will you be bringing? Including yourself.

More - please specify

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* 1. Please complete all fields below.

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* 2. What is your age group?

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* 3. What grade are you in?

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* 4. If you are currently in school, please list your school and location.

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* 5. Please list your emergency contact.

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* 6. Please list any allergies or dietary restrictions you or your guests may have.

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* 7. Will your parents/guardian or an adult be attending with you that day?

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* 8. How many people will you be bringing? Including yourself.

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* 9. Please list the first and last names of all people attending with you.