June 23-27, 2019

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* 1. First Name

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* 2. Middle Name

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* 3. Last Name

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* 4. Gender

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* 5. Name you would like on your Name Tag?

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* 6. Street Address

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* 7. City

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* 8. State

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* 9. Zip Code

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* 10. Home Phone

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* 11. Cell Phone

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* 12. Email

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* 13. Upload a copy of your high school transcript

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
Choose File

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* 14. Upload a copy of your medical card

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
Choose File

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* 15. Transportation and Media Release
I (the parent) hereby authorize the University of Findlay and the College of Pharmacy to transport my child via university busing, as needed. I  (the student) hereby grant UF the absolute and irrevocable right and permission, with respect to photographs and videos taken of me and/or comments made by me or in which I may be included with others, to copyright for same; to use, reuse and publish the same in whole or in part in any and all media including use on the world wide web, now or hereafter, and for any purpose whatever for illustration, promotion, art, advertising and trade, and if appropriate, to use my name and pertinent education and/or biographical facts as UF chooses.

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* 16. How old are you?

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* 17. Date of Birth

Date

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* 18. Current High School Name

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* 19. High School Graduation Year

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* 20. T-Shirt Size

Emergency Contact Information

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* 21. Indemnification
My child wishes to participate in the University of Findlay and the College of Pharmacy Summer Camp in June 2019. I (the parent/guardian) acknowledges that my child is in good health and good physical condition. I understand that there are risks inherent in any physical activity. I assume the risks and accept the consequences involved in my participation in this event. I understand that if my child is injured, I am responsible for health care costs and I agree to release the University of Findlay, its Board of Trustees, officers, agents, employees, volunteers, or current students from any and all claims for injury or illness resulting from my child's participation in this event. I also understand that the rules and regulations that govern student conduct will be in effect during this event. In the event of my child's illness or injury and reasonable attempts to contact me (the parent/guardian) at my telephone have been unsuccessful, I hereby give my consent to have any treatment deemed necessary by a local licensed physician or dentist and the transfer of the child to Blanchard Valley Hospital, if necessary.

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* 22. Emergency Contact #1

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* 23. Emergency Contact #2

Camper Information

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* 24. Do you have any special dietary needs?

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* 25. Do you have any allergies?

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* 26. Are you currently taking any medications?

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* 27. Do you have any physical impairments to which a physician should be alerted?

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* 28. Any other needs we should know about?

Camper Education Information

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* 29. List any pharmacy related courses taken since the beginning of high school (indicate if honors, AP, IB class, etc.)

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* 30. List any extracurricular activities

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* 31. Why are you attending this summer camp?

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