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Name _______________________________________________________________________ Home Address ________________________________________________________________ City __________________________________ State __________________ Zip____________ Telephone No. (Home) ________________________ Grade Level ______________________ Why do you want to attend Moon Bases, Terraforming, and Interstellar Travel Camp 2016? _____________________________ ____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 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 are due by July 16, 2016
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