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, January 21, 2012 (States of Matter)

Registration Deadline:  Tuesday, January 17, 2012 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, February 11, 2012 (Literature Alive)

Registration Deadline:  Monday, February 6, 2012 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.