Summer 2008 Application Form

A Celebration of Life XIII
Summer Sessions 2008

STUDENT DATA

Student's Name
School
Fall 2008 Grade
Allergies
Address
City
State
ZIP
Home Phone(s)
Date of Birth
Gender	Male Female
Applying as an African American Ethnic Academy student? Yes No

PARENT/GUARDIAN DATA

Name (primary contact person)
Address
City
State
ZIP
Home Phone(s)
Work Phone
E-mail Address

Name (second contact person)
Address
City
State
ZIP
Home Phone(s)
Work Phone
E-mail Address

Please check the session of interest to you:

I. Grades 3-5: June 16 - 27, 2008, 8:30-12:00, M-F mornings; Environment! ($140)

II. Grades 6-8: July 7 - 18, 2008, 8:30-12:00, M-F mornings; Environment! ($140)

(or print and mail to Virginia Henderson, see address below)

FOR MORE INFORMATION

Program description
Contact: Barbara Bielec, K-12 Program Coordinator
BioPharmaceutical Technology Center Institute (BTCI)
5445 East Cheryl Parkway
Madison, Wisconsin, USA 53711
608-277-2618; FAX:608-273-6992
e-mail: barbara.bielec@btci.org
Contact: Dr. Virginia Henderson, President
African American Ethnic Academy
P.O. Box 55026
Madison, WI 53705
608-274-5808
e-mail: vmhender@hotmail.com

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