Registration Form

Date:

Please insert today's date

Enrollment:

When do you plan to begin your enrollment?  Check all that Apply.

Enrollment Year:

(Enter 4-digit year that you first attended the Institute eg: 2019)

Student Status (Check One)

Please select your course(s)
Student Information:

First Name:

Last Name:

e-mail Address (required):

Phone Number:

Please include Area Code in the following format:  (555) 555 5555

Permanent Address:

Street Address 1:

Street Address 2:

City:

Zip Code:

State:

Mailing Address:

Street Address 1:

Street Address 2:

City:

State:

Zip Code:

References

Name three or more persons acquainted with your academic and/or professional experience.  Please include at least three Recommendation Letters.  Please have each reference listed.  Recommendation letters can be e-mailed to info@pocsinstitute.org.  Please have them indicate your name as the student in the letter. 

**If you have already completed this step in a prior semester please continue to submit your registration

Reference #1:

First Name:

E-Mail:

Street Address 1:

Street Address 2:

Last Name

U.S. Phone Number:

Please include Area Code in the following format:  (555 555 5555)

City:

State:

Zip Code:

Position

COVID 19 Questionare

 PLEASE READ EACH QUESTION CAREFULLY and answer honestly to the best of your ability.

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1.Have you experienced any of the following symptoms in the past 48 hours:

•fever or chills

•cough

•shortness of breath or difficulty breathing

•fatigue

•muscle or body aches

•headache

•new loss of taste or smell

•sore throat

•congestion or runny nose

•nausea or vomiting

•diarrhea

 If you have had any of the above symptoms in the 48 hours preceding the event, DO NOT come to the intensive until symptoms have subsided for more than 48 hours. If you have a chronic medical condition that causes COVID-19-like symptoms, please obtain medical documentation from your primary care physician or call CDC’s Occupational Health Clinic (OHC) at 404-639-3385 to determine whether you can safely be granted access to our Intensive. Fully vaccinated individuals should not access the Watson Homestead facility  if they are currently experiencing any of the above symptoms. 

2. Are you isolating or quarantining because you tested positive for COVID-19      or are worried that you may be sick with COVID-19?

 If you have concerns about being exposed to or sick with COVID-19, please stay home and self-quarantine or isolate. Read more about when you should be in isolation or quarantine (https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html). If you have questions about when it is safe to resume your normal activities please call CDC’s Occupational Health Clinic (OHC) at 404-639-3385 or your personal physician.

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To be considered fully vaccinated, you must be ≥2 weeks following receipt of the second dose in a 2-dose series or ≥2 weeks following receipt of one dose of a single-dose vaccine. 

3. Are you fully vaccinated OR have you recovered from a documented COVID-      19 infection in the last 3 months?

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4. Have you been in close physical contact in the last 14 days with: 

• Anyone who is known to have laboratory-confirmed COVID-19? 

OR 

• Anyone who has any symptoms consistent with COVID-19? 

Close physical contact is defined as being within 6 feet of an infected/symptomatic person for a cumulative total of 15 minutes or more over a 24-hour period starting from 48 hours before illness onset (or, for asymptomatic individuals, 48 hours prior to test specimen collection). 

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If you have been in close contact with someone with COVID-19, you should stay home and self-quarantine for 14 days before returning to your regular activities . Read more about when you should be in isolation or quarantine (https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html)  

5. Are you currently waiting on the results of a COVID-19 test? 

 

IMPORTANT: ANSWER “NO” IF YOU ARE WAITING ON THE RESULTS OF A PRE-TRAVEL OR POST-TRAVEL COVID-19 TEST 

6. Do you expect to travel in the10 days leading up to the intensive? 

 

Travel is defined as any trip that is overnight AND on public transportation (plane, train, bus, Uber, Lyft, cab, etc.) OR any trip that is overnight AND with people who are not in your household 

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Businesses have specific requirements to ensure Personnel stay safe. Watson Homestead may have additional screening requirements or forms to use.

I certify that my responses are true and correct 
Payment Information:

Each course cost $360.76 USD.  You are not completely registered until the course is paid for.  Online payments include PayPal fees. All payments are non-refundable

Upon submission of this form, you will be taken to a page where you can pay for your course

Summer Intensive Registration 2021

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175 St. Bridget's Drive

Rochester, New York

14604