MC² Youth Participant Application

First name*

Last name*

Email*

Phone*

Address (residence)*

Parent/Guardian name

Address (if different than above)

Parent/Guardian Email

Parent/Guardian Phone

Interested Session*

Session 1

Session 2

Transportation assistance needed*

Yes

No

Food Allergies*

Yes

No

Additional information/comments

Phone : (860) 212 8164

Mailing Address

MC² Technology, Inc.

P.O. Box 2023

Hartford, CT 06145-2023

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