Spend-A-Day with the School of Pharmacy

Student Information

First Name*

Preferred First Name

Last Name*

Birthdate*

Contact Information

Permanent Home Address*

Country

Street

City

Region

Postal Code

Student Cell Phone Number*

Student Email Address*

Parent/Guardian Information

Would you like to provide parent/guardian contact information?

Yes

No

Relationship Type

First Name

Last Name

Cell Phone Number

Email Address

Academic Information

Current High School Attending*

High School Graduation Year*

Intended Major*

Pre-Professional Program (If applicable)

Visit Information

Would you like a campus tour at the end of the program?

Yes

No

Total Number Attending (Including Student)*

1

2

3

Special Needs or Accommodations