G.E.M.S (Girls Enjoying Math and Science) July 11 and 12, 2022 Application Form

Held at SMART Centre Market, 30 22^nd Street, Wheeling, WV

Name ________________________________________________________________________

Home Address ________________________________________________________________

City ___________________________________ State __________________ Zip____________

Telephone No. (Home) ______________________________  Grade Level  ________________

Why do you want to attend GEMS 2022?  ______________________

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Parent/Guardian Name: ___________________________  Phone number _________________

Emergency phone number ________________________  Name of contact ____________________

E-mail __________________________________________________________________________

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: