APPLICATION FORM

A Celebration of Life XV - Summer Sessions 2010

Student Data

Student's Name
School
Fall 2010 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: July 6-16, 2010, 8:30-12:00, M-F mornings; Healthy Planet! ($140)

II. Grades 6-8: July 19 - 30, 2010,  8:30-12:00,  M-F mornings; Healthy Planet! ($140)

    

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

  • PROGRAM DESCRIPTION (to be updated Feb. 2010)

  • 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

    Dr. Virginia Henderson, President
    African American Ethnic Academy
    P.O. Box 55026
    Madison, WI 53705
    608-274-5808
    e-mail: vmhender@hotmail.com