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Name _______________________________________________________________________ Home Address ________________________________________________________________ City _________________________________ State __________________ Zip____________ Telephone No. (Home) _________________________ Grade Level _______________________ Why do you want to attend Moon and Mars Camp 2007? _______________________________ _____________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Parent/Guardian Name: ___________________________ Phone number _________________ Emergency phone number ________________________ Name of contact ____________________ Name of Family Doctor: _________________________ Phone number: ____________________ Allergies/medications taken: _________________________________________________________ Other medical information: __________________________________________________________ Please call Elizabeth Strong at (304) 277-2308 or e-mail strongli@westliberty.edu if you have any questions. Please fill out form completely and mail
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Applications are due by August 7th, 2007...
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