Rural Pharmacy Camp at Eastern Illinois University

Rural Pharmacy Camps Registration Form

SECTION 1: Contact Information

First Name

Last Name

Preferred Name

Preferred Pronouns

Mailing Address

Country

Street

City

Region

Postal Code

Email Address

Mobile Phone

Do you consent to receiving text messages from UIC Retzky College of Pharmacy?

Yes

SECTION 2: Current Education Information

I am a current:

High School Student

College Student

What high school do you currently attend?

What is your current year in high school?

What college/university do you currently attend?

What is your major or emphasis?

SECTION 3: Demographics

Gender

Female

Male

Nonbinary

Race (select any that apply)

Are you Hispanic or Latino?

Yes

SECTION 4: Interest in Pharmacy

When you think of the job of a pharmacist, what comes to mind?

What do you hope to learn by attending this pharmacy camp?

Hidden - default recruit program - PharmD

SECTION 5: Supporter Track

Will your Parent/Guardian/Other Supporters attend the Supporter Track?

Yes

How many people will attend the Supporter Track? Please note that at this time, the maximum number of guests for the Supporter Track is 2.

Name of the individual(s) who will be attending the Supporter Track, if applicable.

Email address(es) for the individuals who will be attending the Supporter Track, if applicable.