Student Registration Form

Event Details:

Place: Helix AI & Medical Academy

220 Town Blvd, Opelousas, LA 70570

Time: 9 am- 3 pm

Who is allowed to attend: High school and college students

Contact us at:

lafuturehealthcareleaders@gmail.com

www.lafuturehealthcareleaders.org
Student Registration Form

Please use this form to register for the Pre-Health Career Conference being held at Helix AI & Medical Academy in Opelousas, Louisiana on July 31st, 2026 from 9 am to 3 pm. All students who register early will be guaranteed admission into the conference and free lunch.
- Full Name*
  
  First NameMiddle InitialLast Name
- Email*
- Phone Number*
  Format: (000) 000-0000.
- Birth Date
  
  MonthDayYear
- Emergency Contact*
  
  First NameLast Name
- Relationship*
  ex. Father, Mother, etc.
- Phone Number Of Person To Contact In Case Of Emergency*
  Please enter a valid phone number.Format: (000) 000-0000.
- Email Of Person To Contact In Case Of Emergency*
  example@example.com
- Will a parent or guardian be accompanying you to the conference? (If yes, please fill out the next section.)*
  
  YesNo
- Parent or Guardian Name
  
  First NameLast Name
- High School Name*
  For the 2026-2027 school year.
- Classification *
  Ex: High school freshman.
- What Is Your Plan After High School?*
- Are you currently a college or university student? (If yes, please fill out the next section.)*
  
  YesNo
- College or University Name
- Classification
  Ex: Freshman.
- Major or Program Name
  Ex: Pre-medical biology.
- What Is Your Plan After College?
- What Are You Looking Forward To Learning About Most At This Conference?
- Please verify that you are human*
- Should be Empty: