2009 SENIOR SUMMER CAMP REGISTRATION FORM
Please complete all fields. Enter "NA" if not applicable.
PLEASE SUBMIT THIS FORM BY APRIL 15, 2009
Personal Information:
Email Address:
Mobile Phone:
Last Name:
First Name:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Academic Information:
Anticipated Area of Graduate Study:
Current Institution Information:
School Attending:
Expected Graduation Date:
McNair Scholars Program Director:
McNair Scholars Program Phone:
Camp Information:
Would you prefer a vegetarian meal?
Are you bringing a laptop (yes or no)?
What size jacket would you prefer? (SMALL up to 6XL)
Do you have any allergies? (please list all)
Do you have any physical challenges for which you will need accomodations? (please list all)
Emergency Contact Information:
Name:
Phone:
Mobile Phone:
Comments:
Please Remember to Submit this Form by Clicking the SUBMIT Button.