Home Address ________________________________________________________________

City __________________________________  State __________________ Zip____________

Telephone No. (Home) ________________________  Grade Level  ______________________

Why do you want to attend Fun with Physics Camp 2007?  _____________________________

 ____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

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: