Western Wisconsin-Upper Michigan

Student Registration Form

PLEASE PRINT

NAME: ________________________________________________________________

                         (Last)                                         (First)                          (M.I.)

HOME ADDRESS:           _____________________________________________________                                                                                                                    (Street)

                              _____________________________________________________

                                 (City)                                (State)                   (Zip Code)

PARENT'S NAMES: _____________________________________________________

HOME TELEPHONE: ________________________          GENDER:     M        F

EMAIL ADDRESS: ______________________________________________________

SCHOOL: _____________________________________________________________

GRADE LEVEL IN SCHOOL AS OF SEPTEMBER 1 of this year: _________________

HEALTH CONCERNS/SPECIAL NEEDS:

          ______________________________________________________________ __

          ________________________________________________________________

Have you previously attended JSHS?                              YES _____ NO _____

Is there a possibility that you may present

a research project at the symposium?                      YES _____ NO _____

Tentative Project Title: _________________________________________________

                                                                                                              (Date)

PRINCIPAL'S SIGNATURE:           __________________________________________

                                                                                                              (Date)