Heartland High School Doc for a Day Registration - April 25, 2025

Thank you for registering for Doc for a Day! This program will give you a chance to learn directly from healthcare professionals.

Please take a few minutes to answer these questions. Some of the questions (ethnicity, race, gender, background) are required by our federal funder.

Completion of the survey is mandatory for participation, but NONE of your responses will impact your eligibility for participation and your personal information will not be shared.

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* 1. What is your name? (to be used strictly for coordination of this event - will not be shared with anyone else)

First name

Last name

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* 2. What is your email address? (to be used only for communications relative to this activity)

Email address

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* 3. Please provide the name of your parent/guardian:

First name

Last name

Heartland High School Doc for a Day Registration - April 25, 2025

Question Title

* 1. What is your name? (to be used strictly for coordination of this event - will not be shared with anyone else)

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* 2. What is your email address? (to be used only for communications relative to this activity)

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* 3. Please provide the name of your parent/guardian:

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* 4. What is your parent/guardian's email address? (Permission forms will be emailed to your parent/guardian before the event.)

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* 5. Please provide the best phone number for your parent/guardian:

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* 6. What school do you attend?