Home Address ________________________________________________________________

City _________________________________  State __________________ Zip____________

Telephone No. (Home) _________________________  Grade Level  _______________________

Why do you want to attend Moon and Mars Camp 2011?  _______________________________

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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)23-DINOS or e-mail libby@smartcenter.org if you have any questions.

Please fill out form completely  and mail to: