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Please provide license number (if applicable):
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If you marked "Student" or "Other Healthcare Provider" above, please provide additional information/area of study or expertise:
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Credentials (if applicable):
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Place of employment (if applicable)
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Last year of school completed (or year you graduated):
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Please provide your emergency contact information, including address and day/evening phone number:
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Do you have malpractice insurance?
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Have you worked at a diabetes camp in the past?
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Please describe your work experience:
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Please describe your experiences with diabetes:
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What are your goals/reasons for attending diabetes camp?
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CAMP SCHEDULE:
My first preference is the week of:
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CAMP SCHEDULE:
My second preference is the week of:
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CAMP SCHEDULE:
My third preference is the week of:
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If there is a week you are not available, please select:
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What is your tee shirt size:
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Please upload your completed Medical History Form:
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(Allowed extensions: *.doc, *.docx, *.jpeg, *.jpg, *.pdf, *.png)
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Please upload your completed Affidavit Disclaimer Form:
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(Allowed extensions: *.doc, *.docx, *.jpeg, *.jpg, *.pdf, *.png)
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