I HIGHLY RECOMMEND MAILING IT IN AS THE EMAILING SUBMISSION DOES NOT WORKS AS OF NOW!

Introduction to Careers in Health Care

Student Career Club Registration/Permission

Student Information:

Name: *

Date of Birth: *

Grade: *

School: *

Street Address: *

City: *

State: *

Zip code: *

Preferred Phone: *

Email: *

Parent Information:

Name: *

Street Address (if different):

City:

State:

Zip code:

Preferred Phone:

Email:

Health/Medical Information:

Allergies (food or environmental):

Does your child carry an Epi Pen?

Do they know how to administer it?

Do you have any other health or behavior concerns?

For which University of Maryland Campus are you registering your student?

Cambridge:

Chestertown:

Denton:

Easton:

Queen Anne’s:

Emergency Contacts:

Name: Relationship: Phone:

Authorized Person to pick up my child:

Name: Relationship: Phone:

Mailing Address:

114 S Washington St

Easton, MD 21601

I would like to print a physical copy to send through the mail.