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Area Health Education Centers of Oregon
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Registration Request
Instructions
Use this form to register for Virtual Dental Careers Camp.  The program is conducted at Virtual Camp 2020 Dental Health Careers  and is scheduled to begin 5/15/2020 If you have questions about the program you can direct them to the instructor at  jlabahn@samhealth.org.  Fields marked with an asterisk (*) are required.
Student Info
*First: *Last:
A home phone or mobile phone is required.
Home: XXX-XXX-XXXX Mobile: XXX-XXX-XXXX
*Email: *Birth Date: Pick a date
*Address: *City:
*State: *Zip Code:
*County: *Gender:
*HS Grad Yr: *Bilingual:
*School:
Career Interest
*Career: Other Career:
Demographics
*Ethnicity: *Parent1 Education:
*Race: Parent2 Education:
Can you answer yes to any of the following? 
  - You are (or will be) the first generation in your family to attend college.
  - While growing up, you or your family ever used federal or state assistance programs (such as: free or reduced
    school lunch, subsidized housing, food stamps, Medicaid etc.).
  - While growing up, you lived where there were few medical providers at a convenient distance.
  - One or more adult household members is unemployed or furloughed.
Parent Contact Info
*Home Lang:    
  First Name Last Name Phone
*Parent1:
Parent2:  
*Emergency
Contact:
 
*Parent1 Email:

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