Pathways to Health Careers - Registration

First and Last Name: *

Email Address? (If you are a high school student, please use your chaperone's email address.) *

What school do you attend? *

What is your home address zip code? *

What grade are you in? (Please check one) *

9th Grade

10th Grade

11th Grade

12th Grade

1st Year CCRI

2nd Year CCRI

3+ Years CCRI

Other College/Adult Education

Not currently in school

If you are a high school student, what is the first and last name of your chaperone? *This should be the name of the person who will be at the event with you from your school.

Please select your first choice for attending this event from the list below. *Your teacher should provide this information, if applicable.

Please select your second choice for attending this event from the list below. *Your teacher should provide this information, if applicable.

What career areas and pathways are you most interested to learn about? (Please choose all that apply) *

Allied Health

Dental

Emergency Management

Nursing

Rehabilitative Health

Social Services

Health Administration

Undecided

How did you learn about the event? (Please choose all that apply) *

Teacher

School guidance counselor

Social media

Poster

CCRI newsletter or email

Friend

Do you hereby give your consent and permission to Community College of Rhode Island and its associates and clients and any media or communication, or otherwise they may designate, to use in any manner they deem advisable your name and/or photograph or video in its advertising and/or communications, and make such use, if they deem advisable, of your written statements in letter form or otherwise either in conjunction with your name or apart from it or in connection with another name; and you do hereby release said Community College of Rhode Island from any and all claims and demands arising from said use? *

Yes - I am 18 years or older and give my consent and permission

No - I am 18 years or older and decline

I am under 18 years of age and cannot consent

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Pathways to Health Careers - Registration