Kids on Campus Application

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

9:00-12:00 PM Saturday, December 12, 2009

Registration Deadline: Tuesday, December 8, 2009

Course number ____________ Fee _____

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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