Registration Form - Pharmacy Preview Day 2016

Note: Red * text indicates required fields

Personal Information

First Name, Last Name *
Address One *
Address Two
City, State, Postal Code *
Phone Number
[999-999-9999 x999]
E-mail Address *
Major Interested in
Birthdate *

High School and Church Information

High School Name *
High School City *
High School State *
Graduation Year [yyyy] *
Church Name *
Church City *
Church State *

Housing Information

If you are coming Thursday, please plan to arrive between 5:00 - 7:30pm.
Time of Arrival (if on Thursday)

Student Housing

Event Details

Total people attending (please include any parents or siblings who plan to attend) *
Additonal Comments


Total Amount: $