Please Print Out The Registration
Form Below & Mail It With Your
Registration Fee To:
Ely Chapman Education
Foundation
403 Scammel Street
Marietta, OH 45750
|
Registration Application
Name:___________________________
Last First MI
Address:__________________________
________________________________
City State Zip Code
Home phone:_________________________
Cell phone:_________________________
Birth date:__________ Age:____________
School:____________________________
Grade Completed Spring 2011: ___________
T-shirt size_______
Parent/Legal Guardian’s Name:
________________________________
Last First MI
I am interested in attending
(please check):
[ ] June 6 - June 10
[ ] June 13 - June 17
[ ] June 20 - June 24
[ ] June 27 - July 1
[ ] July 5 - July 8
[ ] July 11 - July 15
[ ] July 18 - July 22
[ ] July 25 - July 29
[ ] August 1 - August 5
[ ] August 8 - August 12
[ ] August 15 - August 19
[ ] All Eleven Sessions