WSU C2 Summer 2023 On-Campus Registration

Camps are Monday - Thursday 10am -3pm.

July 10, 2023 - July 13, 2023

July 17, 2023 - July 20, 2023

July 31, 2023 - August 3, 2023

Lunch is provided!

Camp Fees:

Students that attend one of our C2 Sites, Camps are Free!

Non C2 Pipeline Schools

Weekly fee: $100

Students that receive reduced lunch, the cost for camp is $50 per week.

Students that receive free lunch, the cost for camp is $25 per week.

Fields with asterisks (*) are required.

First name *

Last name *

Email *

Birthdate *

School Attending in Fall 2023 *

School name (If not listed)

Grade (The grade you will be in Fall 2023) *

UIC/Student ID #

Address line 1 *

Address line 2

City *

State/province/region *

Postal/zip code *

Country *

Gender *

Pronouns

Ethnicity

Hispanic or Latino

Arab or Middle Eastern

Receives Free or Reduced Lunch *

Shirt Size *

Parent/Guardian Information

First, Last Name *

Relationship to Student

Email Address *

Phone Number *

Address *

City *

State *

Zip Code *

First, Last Name

Relationship to Student

Email Address

Phone Number

Emergency Contact

First, Last Name *

Email Addrfess

Phone Number *

Relationship to Student

Medical Information

Are there any medical reasons/disabilities that prevent your child from participating in certain physical activities?

Yes

Allergies

Medical Concerns

Camp Selection(s)

Week 1 Camps (July 10, 2023- July 13, 2023

Week 1 Camps (Second Choice Camp)

Week 2 Camps (July 17, 2023 - July 20, 2023

Week 2 Camps (second choice)

Week 3 Camps (July 31, 2023 - August 3, 2023)

Week 3 Camps (Second Choice)

Transportation

Student will be dropped off/picked up from Wayne State Campus

Student will ride Bus (information will be provided at a later day)

Free or Reduced Lunch Eligibility Form

I hereby give permission for the above student to take part in the Wayne State University C2 Pipeline ("Program") activities, which may include off-campus events, academic assistance, college/career and group counseling, continuing education, recreational programming. If a medical emergency arises, I understand Program staff will secure emergency medical and or emergency surgical treatment for my enrolled child. I understand that I will be responsible for any emergency transportation charges and medical expenses incurred. I voluntarily give my consent to Wayne State University and those acting to their authority on behalf of the Wayne State University C2Pipeline Program to record my child's participation and appearance on video tape, audio tape, film, photograph or any other medium during program activities. Any recording/photo or tape may be used by Wayne State University for education and public relations purposes which may include social media or public access websites. I further give my consent for my child's school to share the student's academic records with the Wayne State University C2 Pipeline Program for purposes of providing educational support and assistance. In addition, I understand that Wayne State University will use participant records only to evaluate my child's individual progress and improvement, as well as to evaluate the impact of the program on my child's achievement and to obtain continued funding for the program. I hereby certify that I have read and do understand the above information, the program rules, and I agree to them. *

*Parent/Guardian please enter name and date to agree to these terms* *