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Nurse In Action Participant Sign Up
Thanks for your interest in the Nurse In Action program at Methodist College! Please fill out the form below in order to get you registered for this program. Questions? Contact
gfletcher@methodistcol.edu
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* Indicates required question
Email
*
Your email
Select the date in which you would like to attend.
*
March 24th, 2020
April 14th, 2020
April 21st, 2020
First & Last Name
*
Your answer
Phone Number (XXX-XXX-XXXX)
*
Your answer
Birth date (you must be 16 years of age or older to participate)
*
MM
/
DD
/
YYYY
Current high school or college you attend
*
Your answer
Will be coming to the College for a tour of the campus and apartments immediately after your shadowing experience is completed?
*
Yes
No
Maybe
Emergency Contact Name and Relationship to Participant
*
Your answer
Emergency Contact Phone Number
*
Your answer
Emergency Contact Email
*
Your answer
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