ࡱ> nqm_  bjbjzyzy q6b6b*x x hhh|||||X@===???????$hDG|?h=|===? @=Rh?=?;F"> @S"<"?(@0X@<GuGD>Gh> ===??===X@====G=========x B :  National Center for Bioethics in Research and Health Care  Application Form NAME: _________________ ________________ __________ [Last] [First] [Middle] Age: ___________________ Date of Birth (MM/DD/YYYY) ________________ Male: _____________________ Female: _____________________ Macon County Address: ___________________________CITY____________ STATE_____ ZIP______ Do you have transportation to & from campus once a month on weekend? _________ Yes__________ No (Check one) Participant Cell Telephone: Area Code: ________ Number: ____________ Parent & Guardian Name: _______________________________ Address Parent & Guardian: ________________________________ Parent & Guardian Best Telephone Contact: ______________________ Participant e-mail: __________________________________ Parent Email: ________________________________________ School Attending: _________________Classification:__________________________ (High School) (Sophomore/Junior) I will devote the time and resources necessary to complete the BB program. This includes attendance, participation, behavior, attitude, standards set by program. I understand the above commitments and agree in signing this application to be bound by them. Applicant Signature: _____________________________ Date: ___________________ Ƶ & MACON COUNTY BRIDGE BUILDERS PROGRAM DOCU 1200 West Montgomery Road, John A. 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