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NRCC Student Registration

Instructions: The application must be submitted online. It should be filled out and submitted all AT ONE TIME. To preview the questions before you enter the data, either peruse the online sections or download the pdf for review. ALL FIELDS REQUIRE AN ENTRY, except where previous answers render fields inapplicable. Once all 5 sections have been completed, press SUBMIT.


First Name: Middle Name: Last Name:
Street Address: City:
County: State: Zip Code:

Your Home Phone: Your Cell Phone:
() - () -
Your Email Address: Gender:
Male Female
Your Date of Birth: Your T-shirt Size:
/ / Small Medium Large X-Large
Parent/Guardian Email Address: Verify That You Are Human:
one plus 6 equals (spell it out)  

Entering Year in School in September 2012:
Freshman Sophomore Junior Senior
Name of High School:
Street Address: City:
State: Zip Code:
School Phone: Principal:
() -
Are you planning to attend college?
Yes No
In which natural resources area of study are you most interested?

Is your child covered by medical insurance?
Yes No
If Yes, Insurance Company:
If Yes, Policy Number: If Yes, Policy Holder:
If Applicable, Prescription Insurance Company:
If Applicable, Policy Number: If Applicable, Policy Holder:
Mother/Guardian First Name: Mother/Guardian Last Name:
Street Address: City:
State: Zip Code:
Day Phone: Evening Phone:
() - () -
Father/Guardian First Name: Father/Guardian Last Name:
Street Address: City:
State: Zip Code:
Day Phone: Evening Phone:
() - () -
Emergency Contact First Name: (other than parent/guardian) Emergency Contact Last Name: (other than parent/guardian)
Street Address: City:
State: Zip Code:
Day Phone: Evening Phone:
() - () -
- For Parents/Guardians -
Do you know of any health factor that makes it advisable for your child to follow a limited program of physical activity while participating in the Natural Resources Careers Camp?
Yes No
If yes, please describe:
Is your child on any prescription medication?
Yes No
If yes, please describe:
Does your child require a special diet?
Yes No
Is your child a vegetarian?
Yes No
Does your child have allergies?
Yes No
foods asthma hay fever poison ivy bee stings other allergies
If yes, please describe:
Has your child had a tetanus shot?
Yes No
If yes, most recent shot date:
/ /

Write a paragraph (125 to 150 words) describing why you are interested in attending NRCC 2012.
List your outside activities (clubs, volunteer work, scouts, etc.).
List awards or special recognitions you have received.
How did you learn about NRCC?

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