Registration for HHMI - WEBS

Your First Name
Your Last Name
Street Address
City, State ZIP
Name of School:
Age: Grade:
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