Scrubs Camp Registration Listen Student InformationStudent Name * Required First Last Student Address * Required Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Student Phone * RequiredStudent Email * Required Student Date of Birth - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Student EthnicityCaucasian/WhiteAfrican AmericanAsianHispanic/LatinoNative AmericanOtherStudent School * Required Student grade - Spring 2022 * Required7th8th9th10th11th12thT-shirt Size * RequiredXSSMLXLXXL3XL4XLFood Allergies? Interested in healthcare career?YesNoUnsureHealthcare career(s) you are interested in pursuing? * Required LIABILITY & PHOTO WAIVER Your signature below authorizes Northwest Iowa Community College, Iowa Intermediary Network and Local Healthcare Partners to be referenced periodically to evaluate the Scrubs Camps. In consideration of the student’s acceptance into and participation in the Scrubs Camp, any and all claims that the student and/or the student’s parents, guardians, heirs, agents, representatives, successors or assigns might have against Northwest Iowa Community College, its employees, contractors, grantees, sponsors, officials and volunteers, for any and all injury or illness which may directly or indirectly result from the student’s participation in this program are waived by signing below. By signing below, the facilitators of the Scrubs Camps are granted the non-exclusive and irrevocable rights and license to make, edit, and use pictures for publicity, news or advertising; including print, video, broadcast media and the internet. The facilitators of the Scrubs Camps are released from any and all claims of payment for performance rights, residuals or damages for libel, slander, invasion of privacy, or any claim based on the use of said material.Parent/Guardian InformationParent/Guardian Name * Required First Last Parent/Guardian Address * Required Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian Phone * RequiredParent/Guardian Email * Required Parent Signature * RequiredCAPTCHA
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