Application — 2002 African-American Heritage Arts Camp

Name_____________________________________________________________
         (Last)                  (First)                  (Middle Initial)
__________________________________________________________________
Street Address                                                          Telephone Number
__________________________________________________________________
City            State              Zip
__________________________________________________________________
Age              Birth Date          Grade Completed by June 2002                  T-Shirt Size

Discipline Interest (select one):
___Dance ___Visual Arts ___Vocal Music ___Drama ___Percussion

Parent/Guardian Name_______________________________________

Telephone Number___________________________

Parent/Guardian Signature_____________________________________________
By May 24, 2002, please return completed application and $100 check for camp fee, made payable to West Virginia Division of Culture and History, to:

Stan Bumgardner
West Virginia Division of Culture and History
The Cultural Center
1900 Kanawha Blvd., E.
Charleston, WV 25305-0300.