Youth Program Registration

1. Code:
2. Program Dates:         , 2012
3. Name: First:  Last:
4. Date of Birth: Month:     Day:     Year: 
5. Gender: Male   Female
6. Home Phone: (   ) -  -
7. Parent Name: First:  Last:
8. Email Address:
9. Home Address: Street:
City: State: Zip:
10. Current School:
11. Grade Completed in June '12:
12. Current school district or town of private school:
13. T-Shirt Size: Child Size: Medium Large
Adult Size: Small   Medium Large
14. Previously attended? Yes   No
If Yes, How many years?
15. Want your name on carpool list? Yes   No
16. How did you hear about our program?

Brochure  Word of mouth  PAWLP Website 
School District Website  Teacher  Sign Up for Camp 
Other

17. Emergency
Contact Names &
Contact Numbers:		 Contact #1:
First: 
Last: 
Number:  - -
Contact #2
First: 
Last: 
Number:  - -
18. Medical problems and allergies our staff should know about:   
19. Authorization: Yes, I give authorization  for emergency care through the 911 number (and the University Health Center for West Chester University programs). 
20. Photo and Video Permission I grant permission to the PAWLP staff to take and use photos and videos of my child for promotional materials. My child's name will not be used with the photos and videos.

Payment Information All two-week classes are $250 if paid by June 8, $275 thereafter.

One-week classes in sponsoring school districts are
$175 if paid by June 8, $190 thereafter.

One-week special location classes are $225 if paid by June 8, $240 thereafter.
Two-week special location class is $300 if paid by June 8, $325 thereafter.

Registration is not complete until payment is made.
Date of payment = Date of registration.

Late fee applies to payments received after June 8.

21. Program fee:   
22. Family discount(first child pays full price): Deduct $10 for each additional child in family.  
23. Facility usage fee.
Add $50 for UCF class.
Add $10 for UMOR class.		  
24. Donation: CHECK HERE IF YOU WILL MAKE A DONATION TO OUR SCHOLARSHIP FUND OF $5 OR MORE. Thanks!
Donations helped provide scholarships for 37 students in 2011!
(Amount of Donation)
25. Total payment:  
26. Agreement: Please mail a check to the PAWLP Office or call 610-436-3089 with your credit card information. WCU accepts Visa, Mastercard, Discover, and American Express.

I agree to have my credit card charged to the payment amount.  


Scholarship Information A limited number of scholarships are available. All scholarships are based on need.Financial information and recommendation letters are required. Click here for Scholarship PDF form. Please contact the Youth Programs Office at (610) 436-3089 for further information.

The deadline for scholarship applications is June 8, 2012.