ENROLLMENT FORM

Democracy in Action
June 19-24, 2011
 

 
Title: First Name:  Last Name: 

Age:     Male Female

Birth Date: 

E-mail: 

Home Address: 

City:    State:    Zip: 

Home Telephone:  Cell Telephone: 

Parents' Names: 

Office Telephone: 

Present Year in School: 

Approximate School Grade Average: 

School Name: 

School Address: 

City:    State:    Zip: 

Name and Department of high school teacher closest to your seminar subject: 

Title:   First Name:  Last Name: 

Department:

Your Member of Congress (U.S. House of Representatives): 
(Look it up: www.house.gov)



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