APPLICATION FORM

A Celebration of Life XVI - Summer Sessions 2011

Student Data

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Student's Name
School
Fall 2011 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 20-July 1, 2011, 8:30-12:00, M-F mornings; ($140)

II. Grades 6-8: July 5-15, 2011,  8:30-12:00,  M-F mornings; ($140)

    

FOR MORE INFORMATION, PLEASE CONTACT:

Barbara Bielec, K-12 Program Director
BioPharmaceutical Technology Center Institute
5445 East Cheryl Parkway
Madison, Wisconsin, USA 53711
608-277-2618; FAX:608-273-6992
e-mail: barbara.bielec@btci.org