Nursing Experience Day

First Name

Last Name

Email Address

Birthdate

Mailing Address

Country

Street

City

Region

Postal Code

Mobile Phone

Home Phone

When do you plan to enroll?

Current School

School CEEB Code

Would you like to go on the optional campus tour from 3:50-4:50pm?

Yes

No

Do you require any dietary or physical accommodations for this day?

Yes

No

Please explain.

How many people will be coming with you?

Do your guests require any dietary or physical accommodations for this day?

Yes

No

Please explain.

Should we send the confirmation email to an additional email address?

Yes

No

Additional Email Address