Virtual Pharmacy Camp Registration Question Title * 1. First Name: OK Question Title * 2. Last Name: OK Question Title * 3. Address: Address Address 2 City/Town State/Province ZIP/Postal Code Country OK Question Title * 4. Email Address: OK Question Title * 5. Phone Number: OK Question Title * 6. Date of Birth (MM/DD/YYYY): OK Question Title * 7. Are you male or female? Male Female OK Question Title * 8. Please check all that apply: White Black or African American American Indian or Alaskan Native Asian Hispanic Native Hawaiian or other Pacific Islander Other (please specify) OK Question Title * 9. Name of High School: OK Question Title * 10. School City: OK Question Title * 11. School State: OK Question Title * 12. What will be your classification next year? (August 2021): OK Question Title * 13. Photo Release Consent: Yes No OK Question Title * 14. Parent/ Guardian Full Name: OK Question Title * 15. Parent/ Guardian Email Address: OK Question Title * 16. Parent/ Guardian Mobile Phone Number (please include area code): OK Question Title * 17. Parent/ Guardian Address: Street Address: City: State or US Territory: Zip Code: OK Question Title * 18. Parent/ Guardian relationship to the student: OK Question Title * 19. In 200 words or less, write a short essay below, which provides and conveys why you want to be a participant in the Pharmacy Summer Camp Program. OK DONE
