Health Careers Camp Registration

Sorry, we are no longer accepting applications; we have reached our capacity of 40 students.

Registration requirements:

Complete the registration form below and select the "Print Form" button.
Sign and date the two-page Housing Form.
Sign and date the two-page Youth Camp Medical Form.
Mail the registration, housing and medical forms, along with the $50 registration fee to:

Pennsylvania College of Technology
School of Health Sciences (DIF 22)
Attn: Nate Smyth
One College Avenue
Williamsport, PA 17701

Student Information

Name First
Last

Birth Date Month
Day
Year

Address Street address
Street address 2 (optional)
City
State
ZIP code

Contact Information Home phone
Cell phone (optional)
E-mail

School Information Current grade
Current school

Gender Male Female

Parent/Guardian Information

Full name
Note any special needs and/or dietary restrictions (optional)

Photo Release Do you give Penn College permission to take photographs of your child during the Health Careers Camp activities to be used for future promotion of the program? Yes No

Emergency Contact Information

Full name
Phone number
Relationship to student

Accessibility Statement