Registration for HHMI - WEBS

Your First Name

Your Last Name

Street Address

City, State ZIP

Name of School:

Age: Grade:

Have you attended WEBS in the past? If yes, when:

Your E-mail Address

EMERGENCY CONTACT INFORMATION DURING HHMI-WEBS HOURS (8:30 a.m. - 3:30 a.m.)

Name

Phone

Relationship

List any medical condition below


Payments must be mailed to:
Ms. Debra Chapman - Biology Department
84 West South Street, Wilkes-Barre, PA 18766