Lakeshore Health Care Alliance

Student Information
Name:	First Name	Last Name
Phone:
Email Address:
Address:	Street
Address:	City	State	Zip Code
Parent Information
Name:
Phone:
Work Phone:
School Information
School Name:
Grade:
Age: (2 digit year only. i.e. 17)
School Representative	Name:
	Phone:
	Email:
Emergency Contact Information
Name:
Phone:
Career Experience Session Information
Select Session
Career Information
Career that you are interested in:
Why are you attending a Career Experience?
I have read, signed, and will return the Career Experience Sheet to the facility contact person before my session date.

Lakeshore Health Care Alliance & Fox Valley