Individual Registration Winston-Salem

Thank you for your interest in the Brenner Children's Hospital Young Authors Contest. Please complete the form below to get started.

Age Confirmation	*	I verify that I am over the age of 18 and have authority to register the student named below.

Student's First Name
Student's Last Name	*
Age	*
Grade	*
School	*
School Address	*
City	*
State	*
Zip Code	*
School Phone	*
County in which Student Goes to School	*

Name of Parent or Guardian	*
Name of Adult Facilitator	*
Relationship to Student	*
Address	*
City	*
State	*
Zip Code	*
Phone	*
E-mail	*