MedCamp Application Form

Student Information

Student Full Name

Student Age

Student Telephone (cell / home)

Student Date of Birth

Student Gender

Primary Parent / Guardian Full Name

Primary Parent / Guardian Daytime Telephone

Primary Parent / Guardian Email Address

Secondary Parent / Guardian Full Name

Secondary Parent / Guardian Daytime Telephone

Secondary Parent / Guardian Email Address

Ethnicity

Race

Please check all that apply.

African-American/Black

American Indian/Alaska Native

Asian

Caucasian

Native Hawaiian/Pacific Islander

Unknown

Choose not to report

Student Home Address

Address

City/Town

State/Province

ZIP/Postal Code

Country

School Information

School Name

Student Grade (as of upcoming school year)

Teacher Recommendations

Note:

Please be advised that an application cannot be processed without TWO TEACHER RECOMMENDATIONS. Take care to make sure that the name and email address information you provide for your teachers is accurate - they'll receive emails to these addresses requesting your recommendations.

Teacher 01 Name

Teacher 01 Email Address

Teacher 02 Name

Teacher 02 Email Address

Student Statement of Interest

This section to be completed by student. Please tell us why you would like to participate in MedCamp this year. You can make the text area larger if you need more room.

Student Email Address

Please enter your email address here so that we can send you a copy of your application.

MedCamp Application Form

Contact Continuing Education