Youth Program Registration

Parent Information

Parent First Name: Parent Last Name:
   
Home Phone: Email Address:
 
WCU Employee or PAWLP Fellow: Confirm Email Address:
   
Home Address City State Zip
     
Emergency Contact Name #1: Emergency Contact Number #1:
   
Emergency Contact Name #2: Emergency Contact Number #2:
   
Number of Children Attending:
 
Do you want your name on carpool list?
 
How did you hear about our program?
 
I authorize emergency care through 911 number and University Health Center for WCU Programs:
 
I give PAWLP 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.