Braindance Submissions 2011

First Name
Last Name
Middle Initial
Home Phone
Confirm Phone Number
E-mail
Confirm Email

Enter your Project Title in the space provided below.

Please submit only one online registration form for each project. Please do not submit a different registration form for each student working on the project.  Enter your the names of any additional students in the space provided below.

Enter your class name (example: Biology 1) in the space provided.

Choose one of the following options for the subject of your project:

Art Academic

Please choose your grade below:

9 10 11 12

Enter your School's Name in the space provided below.

Please provide your school's contact information:

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
School Main Office Phone

Enter your Teacher's Name in the space provided below.

Enter your Teacher's Email in the space provided below.

Enter your Principal's Name in the space provided below.

We prefer to receive projects by electronic submission, but we will accept projects via mail or hand delivered. Check the appropriate box below:

I will submit my project files via e-mail
      Please email your project files to:
      Nancy Hubbard
      nehubba@harthosp.org
      Phone: 860-545-7098

I will hand-deliver my project files

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