Home Address ________________________________________________________________

City __________________________________  State __________________ Zip____________

Telephone No. (Home) ________________________  Grade Level  ______________________

Why do you want to attend Dino Camp 2014?  _____________________________

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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: