Registration Form - Pharmacy Camp 2017

June 19–23, 2017
Registration Deadline: June 7, 2017

The Pharmacy Camp requires a registration fee of $400.00 per person. Your registration cannot be confirmed until your credit card information is processed or payment is received in the mail.
Registration fees are not refundable after the registration deadline.

Exchanges/Changes to Registration
Please do not re-register when wanting to exchange or change your registration. All changes must be submitted by email to or by phone at 937-766-4444. Please include name of registrant, organization name, contact information and your desired changes. We will be happy to help in any way that we are able.

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Note: Red * text indicates required fields

Title *
First Name, Last Name *
Address Line 1 *
Address Line 2
City, State, Postal Code *
Phone Number
[999-999-9999 x999]
Parent/Guardian Work Phone Number
[999-999-9999 x999]
Cell Phone Number
[999-999-9999 x999]
Email Address *
School Name *
School City, State *
Church Name *
Church City, State *
Birthday (00/00/0000) *
Grade in School (September 2017) *
T-Shirt Size *
How did you hear about Academic Camps? *   

Travel Information

Housing Information


Special Dietary Needs

Please let us know of any allergies that would require special meals to be prepared for you in our cafeteria. All special meal requests must be accompanied by a letter from your doctor.

Special Housing Needs

Please let us know of any disabilities/medical conditions that would require special housing needs.

Roommate Request

If you are coming with a friend and would like to room with them for the week, please put their name and the camp they are attending in the box below. Only 2 students will be housed per room.

Payment Information

Total Amount: $