STUDENT INFORMATION:

Name NCW #

Address City/ZIP

Home phone Base school

Grade enrolled during 2007-08 year What year should you graduate? 2008

course #

(from 2007-08 catalog)

For what course are you enrolling?

2009

Other

repeat? yes no

Allergies / Medical conditions:

PARENT/GUARDIAN INFORMATION:

Contact name ____________________________________relationship _____________________

Telephone number _________________________email

Alternative contact:

(During day time in case of emergency)

What transportation will the student be using? (WCPSS does not provide transportation for participation in the CHS Summer Program.)

¨ carpool ¨ personal vehicle ¨ other mode:

Make & model car? Tag number:

(Complete this information if the student will be parking on campus.)