UNMC Healthcare Career Day Registration
Tuesday, May 13
8:15am - 2:15pm



Registration Form

* Denotes required field
Press "Continue..." at the bottom of the page when you have completed the form.


Chaperone Contact Information


For liability reasons, an adult must accompany the participating student(s) from each school
Select Number of Chaperones

Click Here For Breakout Session Descriptions

Chaperone 1

*First Name
*Last Name
*Gender
Male Female
*Title(As you would like it to appear on your name badge)
Ms. Mrs. Mr. Dr.
*Relation to Students
Parent/Legal Guardian  Counselor
Teacher                         Other (specify)
*Mailing Address
*City
*Zip
*Phone Number
Fax
*E-mail
Please select any sessions that you would like to attend so that we will have enough seating available.
Session 1
Session 2
Session 3
Are you vegetarian?
Yes  No
Accessibility Accommodations?
Yes  No
Food Allergies?
Emergency Contact Name
Contact Phone
Contact Relationship

Student Registration


We would appreciate your assistance in providing the following information
Select how many students will be registered, then proceed to fill in all information for each student


Click Here For Breakout Session Descriptions

Student 1

First Name
Last Name
Date of Birth
Grade
*Gender
Male Female
Address
City
State
Zip Code
Session 1
Session 2
Session 3
Are you vegetarian?
Yes  No
Accessibility Accommodations?
Yes  No
Food Allergies?
Phone Number
Ethnicity
Emergency Contact Name
Contact Phone
Contact Relationship

Confirmation notices will be sent out by E-Mail to the Adult Sponsor(s) for each school
Please Print The E-Mail Confirmation Page that contains participant information and mail payments and the form to:
UNMC Recruitment/Student Engagement
984275 NE Medical Center
Omaha, NE 68198-4275


Make checks payable to UNMC
Cost is $5 per person. For student fee waivers contact our office for approval

Questions?
If you have any questions, please contact the event planners at
E-mail: careerday@unmc.edu
Phone: 402-559-3809
Fax: 402-559-6796

Registration Deadline: Thursday, April 24, 2014

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