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Personal Information
Below you will answer questions about yourself and your emergency contact.
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* Indicates required question
Email
*
Your email
What is your ethnicity
Black/African American
White
Asian
Hispanic/Latino
Native Hawaiian or Other Pacific Islander
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Proof of Covid-19 vaccination or proof of exemption required. Can you provide proof?
*
Yes
No
Name
*
First and Last Name
Your answer
SSN
*
Your answer
Date of Birth
*
Your answer
Address
*
Your answer
Phone Number
*
Your answer
Day or Evening class
*
Your answer
Scrub Size
*
XS
S
M
L
XL
XXL
XXXL
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