APPLICATION FORM
Sponsored by the Columbia County Medical Society
at Columbia Greene Community College
(Grades KG, 1 or 2 only)
All applications must be postmarked by March 23, 2007.
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:
___________________________________________________________________
_____INDIVIDUAL
_____GROUP
(Grades 1 through 12)
All applications must be postmarked by April 1, 2007.
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:
___________________________________________________________________
Neal Baillargeon, MD, PO Box 785, Grand Union Plaza, Valatie, NY 12184, Att: CCHCC.
Applications will be acknowledged by postcard.
