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G.E.M.S (Girls Enjoying Math and Science) June 25 & 26, 2018 Application Form

FREE-- funded by the Women's Giving Circle of the Community Foundation for the Ohio Valley.

 

Name ________________________________________________________________________
Home Address ________________________________________________________________

City ___________________________________ State __________________ Zip____________

Telephone No. (Home) ______________________________ Grade Level ________________

Why do you want to attend GEMS 2018? ______________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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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 This email address is being protected from spambots. You need JavaScript enabled to view it. if you have any questions.

Please fill out form completely and mail to:
Libby Strong
SMART-Center
30 22nd Street
Wheeling, WV 26003
Applications accepted through June 23rd, 2018