Wright State University Home Page

Office of Pre-College Programs

Kids on Campus

Application/Registration Form

Student’s Name _________________________________________   __  Male  __ Female

 

Student’s Address _________________________________________________________

 

City _____________________________  State ____________  Zip Code______________

 

Home telephone ___________________  Parent’s E-mail__________________________

 

Current Grade Level ______________      Name of School _________________________

 

Mother’s name ____________________   Cell/Work number _______________________

 

Father’s name_____________________   Cell/Work number _______________________

 

Any allergies (food or others) _________________________________________________

 

Course Selection

Saturday, February 2 (CSI)

Registration Deadline: Monday, Jan. 28, 2013 at 5:00 p.m.

 

Course number ____________            Fee _____

(Check One)

_____ Morning Session (9:00 AM - 12:00 PM)

_____ Afternoon Session (1:00 PM - 4:00 PM)

Saturday, March 2, 2013

Registration Deadline: Monday, Feb. 25, 2013 at 5:00 p.m.

 

Course number ____________            Fee _____

(Check One)

_____ Morning Session (9:00 AM - 12:00 PM)

_____ Afternoon Session (1:00 PM - 4:00 PM)

 

Class fees are $25 a session. Each additional sibling registered after the first child will receive $5 off ($20 a session). However, registrations must be completed and submitted together to receive multiple child discount.

Please note: Pictures and/or videotapes may be taken during class and recreation time for use in Wright State University brochures and publicity.

 

Method of Payment

Make personal checks payable to:

Wright State University

 

Amount _________________

 

Personal check number ___________  Date _______

 

____MasterCard             ____Visa             ____Discover


Card number __________________________________

 

Expiration date ___________

 

Name of cardholder _____________________________

 

 

As the parent/guardian of this student, I give   permission for his/her participation in the Kids on Campus Program.

 

Signature ________________________________________________________________ 

Date_____________________________________________________________________

 

 

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Copyright Information © 2004
Last updated 08/2011 by the Office of Pre-College Programs (ch).
Please send comments to precollege@wright.edu.