Print this page, and fax it to the number shown below.
Last Name: __________________________________ First Name: __________________________________ Male ___ Female ___ Date of Birth: _____________________ Social Security #: __________________________________ Address: ________________________________________ City: _____________________________ State: ____ ZIP Code: ____________ Phone ( ____ ) ____________________ E-mail: ______________________________ Hobbies: _______________________________________________________________ Parents'/Guardians' Names: __________________________________ Session Preferred: (1) session 1 _____ (2) session 2 ____ High School Graduation Date: _______ Name of High School: __________________________ Rank in High School Class: _______ out of ______ GPA: _____ / _____ Have you had Physics? Yes ___ No ___ Chemistry: Yes ___ No ___ Years of Math (circle one): 1 2 3 4 Briefly describe why you would like to join IEP next summer: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ If your choice of sessions is already filled, can you attend the other? Yes ___ No ___ Print this sheet and fax it to: 574-631-9260 attention: Ramzi K. Bualuan, IEP Director