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School Information
Area
School
Grade Teacher / Sponsor Principal Last Name
GPA
between 0.0 and 5.0
Science Grade Anticipated High School Graduation Year
Student Information
First Name Middle Initial Last Name
Address Home Phone e.g. 555-555-5555
City Second Phone e.g. 555-555-5555
State Email e.g., user@host.com
Zip e.g. 55555 or 55555-5555 Confirm Email e.g., user@host.com, must be same as Email
Gender Language(s) Spoken
Select all that apply
Birthdate Race/Ethnicity
Shirt Size
Why would you like to become a doctor?
750 characters max

Are you a Kaiser Permanente member? membership not required to participate
Siblings in College/Graduated?
Do you have access to a computer at
Check all that apply
Parent / Guardian Information
1. First Name Middle Initial LastName
Address Home Phone e.g. 555-555-5555
City Second Phone e.g. 555-555-5555
State Email e.g., user@host.com
Zip e.g. 55555 or 55555-5555 Confirm Email e.g., user@host.com, must be same as Email
Relationship to student Education
 
2. First Name Middle Initial LastName
Address Home Phone e.g. 555-555-5555
City Second Phone e.g. 555-555-5555
State Email e.g., user@host.com
Zip e.g. 55555 or 55555-5555 Confirm Email e.g., user@host.com, must be same as Email
Relationship to student Education

Is an interpreter needed at events?

Are you a returning student?