Time & Date                      June 9 – 19,     1:00 – 4:00 pm

                                   Monday Tuesday Wednesday Thursday

Registration fee   $150    ($50 deposit with application, remainder June 9)

Participant's Name   ____________________________________________

Parent’s Name  _______________________________________________

Address          ________________________________________________

Town               ________________________________________________

Phone              _________________        email _______________________

Background Information on Participant

Grade just completed                                              ____________________

Has participant had introductory algebra?               yes    no

Has participant had any geometry?                          yes    no

What science subjects did the participant                ____________________

complete the last two years?                                   ____________________

Does your child have access to a computer and the internet?    yes   no

Since we will be with your child for a few hours each day, does your child have any special conditions about which we should be informed?

___________________________________________________________

Mail to: Dr. Kyle Hathcox  1050 Union University Dr.  UU1885  Jackson, TN  38305