CWES Camp After School Program Registration
Student Name: ______________________________________ Grade: _____
Check the location of your program: School:
Boys & Girls Club:
Amherst
Almond
Male
Iola-Scandinavia
Jefferson
Female
Rosholt
Junction City
Plover
Parent/Guardian Name:
Home address:
City:
State:
Zip:
Email address:
Phone Numbers: Home:
Work:
Cell:
Which number are you best reached at during the time of the program?
Home
Work
Cell
Emergency Contact if person above is unreachable:
Name:
Relationship:
Does your child have any food allergies or dietary restrictions?
Phone Number:
Yes
No
If yes, please describe:
I,
(Parent/Guardian Name), give permission to
(Student Name) to participate in the after school program offered by the Central Wisconsin Environmental
Station (CWES). I understand that there will be simple pre- and post- activities with each session that I will assist
my child in completing at home. I also agree to pick up my child when the program ends, on time, as I know that
the CWES staff may have other schools/sites to go to that same night.
Parent/Guardian Signature:
Date:
PHOTOGRAPHIC/VIDEO RELEASE
I understand that the University of Wisconsin-Stevens Point and the Central Wisconsin Environmental Station
may take photographs and/or videos of program participants and activities. I agree that the University of
Wisconsin-Stevens Point shall be the owner and may use such photos and/or videos relating to the promotion of
future camps and programs. I relinquish all rights that I may claim in relation to the use of said photographs and/or
videos.
Agree
Disagree, please do not take photos
Parent/Guardian Signature:
Date:
Student Section
Agreements:
(check answer)
Do you agree to participate in the activities?
Y
N
Do you agree to be respectful of your fellow classmates, the teacher and the equipment?
Y
N
Do you agree to learn new things and HAVE FUN?!?!
Y
N
Have you attended camp before? (check one)
Where did you attend camp?
Yes
No
For how many years?
Why do you want be in the afterschool program?
Student Signature
Date:__________
Please Return to Linda Gruber:
Save and Email: lgruber@uwsp.edu
Mail: 10186 County Road MM, Amherst Junction, WI 54407
Fax: 715-346-2493
For any questions, call Linda at 715-346-2703