The West Chester Writing Project : Youth Program Registration

Youth Program Registration

Guardian Information

Please make sure you have filled in all required fields with valid information.

Guardian First Name:

Guardian Last Name:

Home Phone:

- Phone (next 3 digits): - Phone (next 4 digits):

Email Address:

Home Address:

City:

State:

Zip Code:

Student Contact Information

Please make sure you have filled in all required fields with valid information.

Is student contact information during camp different than above guardian information?

Yes No

Contact First Name:

Contact Last Name:

Contact Home Phone:

- Phone (next 3 digits): - Phone (next 4 digits):

Contact Email Address:

Contact Home Address:

Contact City:

Contact State:

Contact Zip Code:

Emergency Contact Information

Please make sure you have filled in all required fields with valid information.

Emergency Contact Name #1:

Emergency Contact Number #1:

- Phone (next 3 digits): - Phone (next 4 digits):

Emergency Contact Name #2:

Emergency Contact Number #2:

- Phone (next 3 digits): - Phone (next 4 digits):

Camp Information

Please make sure you have filled in all required fields with valid information.

Number of Children Attending:

How did you hear about our program?

I authorize emergency care through 911 number and University Health Center for WCU Programs:

I give WCWP permission to use photos and video of my children for publicity:

I understand that this camp is designed for students who enjoy writing and reading and that it is not a remedial program.