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Name ________________________________________________________________________ Home Address ________________________________________________________________ City ___________________________________ State __________________ Zip____________ Telephone No. (Home) ______________________________ Grade Level ________________ Why do you want to attend GEMS 2011? ______________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 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:
Applications accepted through June 15th, 2011
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