Camps 2020

Camper Information

Legal First Name *

Legal Last Name *

Preferred Name *

Address *

City *

State *

Zip Code *

Phone Number (include area code) *

E-Mail Address *

Age *

Date of Birth

Gender (How you identify yourself.) *

Male Female Other

If other selected, please specify.

January 2020 Grade *

Select camp(s) attending. *

Girls Plus Math (July 5-10, Grades 6-8) WIU's Summer Science Experience (July 5-10, Grades 9-12) TechVenturing (July 12-16, Grades 7-12) Art: Colorful Minds & Creative Hands (July 12-17, Grades 4-8) Exploring Harry Potter (July 19-23, Grades 6-8) Teaching Our Next Generation (July 19-23, Grades 9-12)

Will your camper be residential (staying on campus) or commuter (travel to & from campus daily)? *

Residential Commuter

Roommate Preference *

How did you hear about our programs? *

Attended Previously Brochure Email Friend/Family Teacher/Counselor Website School Newsletter

School Information

School Name *

School Counselor/Teacher *

City, State, Zip *

Counselor/Teacher E-Mail *

School Phone Number (Include area code) *

Parent or Guardian

Parent or Guardian Name *

Parent E-Mail *

Parent Phone Number (Include area code) *

Payment Information ($100 REQUIRED AT TIME OF REGISTRATION)

Please indicate your method of payment: *

Credit Card - Submit payment below Cash (Must be received 7-10 days from registering) Bring payment to: Western Illinois University, 1 University Circle, Horrabin Hall 8, Macomb, Illinois 61455 Check (Must be received 7-10 days from registering) Make checks payable and mail to: Western Illinois University, 1 University Circle, Horrabin Hall 8, Macomb, Illinois 61455

Name as it appears on credit card:

Please indicate your amount of credit card payment for the registration:

USD Registration

Please indicate your choice of check payment for the registration amount: *

Pay in full

If you have any additional questions, please call the Office of Study Abroad & Outreach at (309) 298-1911. Western Illinois University complies with all federal and state nondiscrimination laws, orders, and regulations. Western Illinois University is an Affirmative Action, Equal Opportunity institution and affirms its commitment in all programs and activities to nondiscrimination on the basis of race, sex, religion, age, sexual orientation, marital status, disability, national origin, and status as a disabled veteran or Vietnam Era veteran.

WIU Outreach Summer Camp