Fun With Engineering Camp    July 10th and 11th, 2017    Application Form

 

Name _______________________________________________________________________

Home Address ________________________________________________________________

City __________________________________  State __________________ Zip____________

Telephone No. (Home) ________________________  Grade Level  ______________________

Why do you want to attend Fun with Engineering Camp 2017?  _____________________________

 ____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Parent/Guardian Name: ____________________________  Phone number _________________

E-mail ________________________________________________________________________

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:

Libby Strong
SMART-Center
30 22nd Street
Wheeling, WV 26003

Applications are due by July 8th,  2017