412 Impact | 2019 Service-Learning Camp

June 26-27, 2019

Required fields are marked with an asterisk(*).

Participant Information

First Name

Preferred Name or Nickname

Last Name

Combined Name

Country

Street Address

City

State or Province

Zip/Postal Code

Citizenship

U.S.Nonresident AlienResident Alien

Mobile Phone

Home Phone

All correspondence will be sent to the email provided below.

Verify Email:

Birthdate

(mm/dd/yyyy)

Gender

MaleFemale

Additional Information

What school do you currently attend or did you most recently attend?

Name of school counselor or advisor (write N/A if you do not have one):

Academic and personal interests

Grade entering Fall 2019

Adult T-shirt size

How did you find out about us?

If Other, please explain

Emergency Contact Information

Full Name of Emergency Contact:

Relationship:

Emergency Contact Primary Phone:

Emergency Contact Email:

Name of Additional Emergency Contact:

Relationship:

Additional Contact Primary Phone:

Additional Comments, Questions, or Requests

Verification

By signing below, I agree to the following:

Required

Yes, I understand that I must complete a participation agreement prior to my participation in the camp. Forms will be emailed after payment has been received.

Required

Yes, I understand that refunds will not be offered after payment is received. Students who encounter unforeseen, extenuating circumstances may petition for an exception and should reach out to Heidi Ward, Director of Community & Summer Education at hward@pointpark.edu .

Required

Yes, I certify that the information given on this application is complete and accurate and that I have completed this application with the full knowledge and consent of my parent(s) or legal guardian(s).

Please type your full name as an electronic signature

Full payment is due at the same time as registration. Please select the next button below to be directed to our payment portal.

Please email summercamps@pointpark.edu or call (412) 392-6163 for further information.

Contact Information