The Ninth Annual

Columbia County Health Care Challenge

Sunday, April 23, 2006
from 1:00 to 6:00 pm

Columbia Greene Community College

Columbia County Medical Society

Please print out the application form below and complete. Please print or type.

APPLICATION FORM

Columbia County Health Care Challenge
Sponsored by the Columbia County Medical Society
at Columbia Greene Community College

COMPETITION

_____ POSTER CONTEST (Grades 1 or 2 only)
All applications must be postmarked by April 1, 2006.
The posters are due by April 7, 2006.
They should be sent or brought to Dr Baillargeon at his Valatie or Philmont offices.

Student(s) information
Name, Address, Telephone:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________
School name and Address:

___________________________________________________________________
Teacher's name and Grade:

___________________________________________________________________

COMPETITION

_____INDIVIDUAL PRESENTATION

_____GROUP PRESENTATION
All applications must be postmarked by April 1, 2006.
Early entries are encouraged.

Title of project: _____________________________________________________

Description of project:
___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________
Student(s) information
Name, Address, Telephone:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________
School name and Address:

___________________________________________________________________
Teacher's name and Grade:

___________________________________________________________________

The applications should be mailed to:
Neal Baillargeon, MD, PO Box 785, Grand Union Plaza, Valatie, NY 12184, Att: CCHCC.
Applications will be acknowledged by postcard.