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Telephone No. (Home) __________________________ Grade Level  _______________________

Why do you want to attend Fun with Nanotechnology Camp 2008?  __________________________

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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.

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