Application

Name

Address (street, city, zip)

City

State

Zip Code

Telephone

Email

School:

Grade Level in Fall 2012 JuniorSenior

School activities:

Community activities:

Do you have access to a personal computer? YesNo

Do you have access to a digital camera? YesNo

(Please note: Responses to the questions above do not factor into the Forum's selection process; the VHS will provide resources for those without access to digital equipment.)