Youth Program Registration

Parent Information

Parent First Name:	Parent Last Name:
Home Phone: -  -	Email Address:
Confirm Email Address:
Home Address	City	State - - AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	Zip
Emergency Contact Name #1:	Emergency Contact Number #1: -  -
Emergency Contact Name #2:	Emergency Contact Number #2: -  -
Number of Children Attending: - - 1 2 3
How did you hear about our program? - - Brochure Word of mouth WCWP Website School District Website Teacher Sign Up for Camp Other
I authorize emergency care through 911 number and University Health Center for WCU Programs:
- - Yes No
I give WCWP permission to use photos and video of my children for publicity:
- - Yes No
I understand that this camp is designed for students who enjoy writing and reading and that it is not a remedial program.
- - Yes No