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     Thank you for your interest in Rome Memorial Hospital's Health Care Academy. Please fill out the application below and someone will contact you. 
    There is a $30 registration fee which will be collected upon final approval of your application.

     

    Your Name         

    Date of Birth      

    Address         City         Zip     

    Home Phone           Cell Phone      

    E-mail Address      

    Grade in School (June 2017)      

    School      

    County of Residence      

    Parent or Guardian      Contact Phone Number      

    T-Shirt Size (Adult size)     

    Scrub Size TOP (Adult Unisex Size)      

    Scrub Size PANTS (Adult Unisex Size)      

    Nickname to be put on your RMH badge   

    How did you hear about the Health Care Academy?   

     

    Why do you want to attend the Health Care Academy at Rome Memorial Hospital?      

     

     Have you ever attended one of our camps before?     

    If yes, where?  

     Have you ever been convicted of a crime?      

    If yes, please explain       

     Do you have any special needs we should be aware of in order to accommodate you?      

      If yes, please explain  

       

    Do you have any dietary restrictions we need to be aware of? (ie. allergies, vegetarian, gluten free, etc)  

       


     

     Emergency Contacts

    In the event you or another parent/guardian cannot be reached, please provide two alternate contacts.