2012 KIDS & TEEN COLLEGE REGISTRATION FORM PAGE 1 SUMMER CAMP REGISTRATION FORM
This form MUST be completed for all students who are under the age of 18 and who are attending programs at Penn State Abington. TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN. PLEASE PRINT CLEARLY! Complete one registration form for each student.
STUDENT’S NAME *STUDENT’S SS # or PSU ID # PARENT/GUARDIAN NAME
(Please check box) I am the parent and/or the legal guardian of the above named student and attest that the student is my legal dependent
STREET ADDRESS HOME PHONE # WORK PHONE # BIRTHDATE AGE STUDENT’S GRADE IN THE FALL PARENT/GUARDIAN E-MAIL
By checking this box I agree to allow Penn State to use this email address to communicate with me about this program
CITY CELL PHONE #
*The social security number you provide is for enrollment purposes and will be used by the University to verify your child’s identity for official record keeping and reporting. The SSN will be stored in a confidential repository, it will not be used as a primary source to identify your child within the Penn State system. The PSU ID # will be used as the primary identifier. A PSU ID # will be assigned for the student and will be his/her ID# for life.
Please register this student for the following course(s) COURSE NAME
DATES SCHEDULE # FEE STATE ZIP
Total Amount Due: The Pennsylvania State University’s Federal ID number is 24-6000376.
Please indicate method of payment Enclosed is my: Check / Money Order (payable to: Penn State University) Amount: $
Credit Card Visa MasterCard
Credit Card Number Cardholder’s Name (please print) Amount: $
Expiration Date (Month/Year) Cardholder’s Signature (Required)
All forms must be completed and signed in order for your registration to be complete.
Registrations may be mailed or delivered in person to: Penn State Abington Continuing Education Cloverly Building 1600 Woodland Road Abington, PA 19001
18 WWW.ABINGT
ON.PSU.EDU/YOUTHTEEN
Fax Registrations to: 215-881-7412 Scan & Email Registrations to:
dlb61@psu.edu Phone: 215-881-7400 Online Registration and Information:
www.abington.psu.edu/youthteen
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