Home Address ________________________________________________________________

City ___________________________________ State __________________ Zip____________

Telephone No. (Home) ______________________________  Grade Level  ________________

Why do you want to attend Middle School Girls Science Camp 2009?  ______________________

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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.

Please fill out form completely  and mail to: