Westwood Baptist Church, University Center
Summer Enrichment Program
Online Student Application
Please fill out each question completely and be sure to click "SUBMIT" at the bottom.
Please fill out one application PER CHILD.


STUDENT AND PARENT INFORMATION
Student # 1 Name:
Date of Birth:

Age:
 School:
Grade in Fall:
Parent Name :
Address: City:                   Zip: 
Home Telephone:       Cell Telephone: Work Telephone:     ext       
E-Mail Address:  
Place of Employment: Address:
EMERGENCY CONTACT INFORMATION
(Please note that the Child Health History Record must be submitted prior to enrollment. 
Once you complete electronic enrollment, you will be e-mailed this form)
Name: Name:
Home phone:    Cell:   

Pager: 		Home phone:    Cell:   

Pager:
Work Telephone:                  ext     

E-Mail Address 		Work Telephone:                  ext     

E-Mail Address
Please list any allergies:
 Hospital Choice:     1st 

                                2nd
Release Child to:
ENROLLMENT INFORMATION
Please select weeks in which your child will participate in the Enrichment Program:
(Please note that the Child Program Interest Survey must be submitted prior to enrollment. 
Once you complete electronic enrollment, you will be e-mailed this form)  
Week One: May 27-30           Week Two: June 2-6         Week Three:June 9-13          Week Four: June 16-20        Week Five: June 23-27

Week Six: June 30-July 4      Week Seven: July 7-11      Week Eight: July 14-18         Week Nine: July 21-25        Week Ten: July 28-August 1
FEES
Inclusive of meals, snacks, regular field trips, lots of love and more!
$20.00 registration (non-refundable)  |   $65.00 weekly (for the first child)   | $45.00 weekly (for each additional child in the same family and household)
$25.00 swimming fee (One time)

PAYMENT PLAN (Please Select One) - We do not accept personal checks.  Money Orders or PayPal preferred.
If paying by PayPal we will send you information on how to pay via e-mail.

        I will be paying weekly - paying in advance on Friday before each session.
I will be paying monthly - paying in advance by May 19, June 2, and July 1.
I will be paying for the entire summer - paying in advance by May 23.

Will you be paying via Money Orders or Cash?         YES                 NO

Will you be paying via PayPal?                                       YES                  NO

PERMISSION
We will be taking several field trips throughout the summer.  You will be informed in advance each time a field trip will be taken.  By giving your consent below, you grant the Westwood Baptist Church, University Center Summer Enrichment Program, permission to allow your child(ren) to participate and go on any field trip taken during the program.  Further, you grant permission for your child(ren) to walk or be transported to and from various locations for field trips.  You do not and will not hold Westwood Baptist Church, University Center or its affiliates and subsidiaries responsible or liable for any injuries that may occur during the program to your child(ren). 
Do you grant this permission?       YES          NO               Date:
TO SUBMIT THIS FORM PLEASE CLICK SUBMIT BELOW - PLEASE ONLY SUBMIT ONCE