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Camp Registration
The Apprentice Doctor Summer Camp in Tampa, Florida USA
(July 15 - 19, 2013)
Instructions:
Please take note of all the information in this form & let us know should anything be unclear.
Successful candidates will receive an "Acceptance to Camp Email" within 21 days of submitting their application.
Once you have been accepted you will need to pay a $50 non-refundable registration fee to secure your place at the camp.
The student's parent or legal guardian will have to sign the relevant permission document (see below) then submit or fax it to 916 724-6415.
Student's Name
*
First
Last
Size (for a set of Apprentice Doctor® surgical scrubs)
Extra Small
Small
Medium
Large
XL
XXL
XXXL
Gender
Male
Female
Prefer Not to Answer
Age
*
14
15
16
17
18
19
20
21
Student's Grade
*
Student's Email Address
*
Enter Email
Confirm Email
Student's Contact Number
*
Mailing Address
*
Street Address
Address Line 2
City
State / Province / Region
Zip / Postal Code
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Algeria
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Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
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Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
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Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
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El Salvador
Equatorial Guinea
Eritrea
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Ethiopia
Fiji
Finland
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Gabon
Gambia
Georgia
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Ghana
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Guinea
Guinea-Bissau
Guyana
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North Korea
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Malaysia
Maldives
Mali
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Mauritius
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Mongolia
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Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Northern Mariana Islands
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
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Country
Parent/Guardian's Name
*
First
Last
Parent/Guardian's Contact Number
*
Parent/Guardian's Email Address
*
Enter Email
Confirm Email
Alternative Contact Name
First
Last
Alternative Contact Number
Preferred e-mail address for all camp communication:
*
Student Email
Parent/Guardian Email
Alternate Email
Name of School/college:
Name of Principal:
School's Phone No:
Medical information:
Name of Physician:
*
Phone Number:
*
List any allergies/surgeries/illnesses (indicate "nil" if none):
*
List of chronic medication and instructions for how it is to be taken:
*
Please note:
1. Student will need a copy of the prescription or a letter from attending doctor for travel purposes
2. It is the parent's responsibility to ensure that the student is well informed about the specifics of the medication and prescription
3. It will be the student's responsibility to take his/her medication as prescribed
Name of person other than parent in case of emergency:
*
First
Last
Phone Number:
*
Relationship:
*
Aunt, friend, etc.
Comments:
Students: In order to ensure a high level of excellence at the camp, kindly write a letter addressed to Dr Anton Scheepers. Include information about your academic level and most recent grades, relevant experience and training and also telling us a bit about yourself, your future plans and why you would like to attend the camp.
max. 3000 characters
The Apprentice Doctor® Camp Selection Committee will consider your application and successful applicants will be notified per reply e-mail.
Thank you! We look forward to seeing you at The Apprentice Doctor summer medical camp.
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