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Name _______________________________________________________________________ Home Address ________________________________________________________________ City __________________________________ State __________________ Zip____________ Telephone No. (Home) ________________________ Grade Level ______________________ Why do you want to attend Fun with Physics Camp 2009? _____________________________ ____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 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 to:
Applications are due by August 1st
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