2009 Summer Catalog - Gallaudet University

Section VII: Media Release
Section VIII: How did you learn about our Sports and/or Youth Enrichment Programs?
Through Academic Bowl Brochures or catalogs
School counselor Internet/Search engine
My audiologist/speech therapist Word-of-mouth, peer recommendations
My family/relatives Flyers/posters
Information provided by a Gallaudet recruiter or Admissions Counselor
Gallaudet University website or College of Professional Studies and Outreach website (CPSO)
Other, please specify:_____________________________________________________
Section IX: Payment Information
Type of Payment: Check # ______________ Money Order #________________________
VR or Employer (Completed paperwork must be accompany this application)
Visa Master Card (We accept only Visa and Master Card)
Card Number: ____ ____ ____ ____ - ____ ____ ____ ____ - ____ ____ ____ ____-____ ____ ____ ____
Name on Card:__________________________________ Expiration Date:______________________
Cancellation Policy
No refunds will be given after the registration deadline.
PARENT or GUARDIAN: Please check the registration information for accuracy. Please read the following statement and sign at the point indicated below.
“Admission as a participant to Gallaudet University Youth Program carries many privileges and responsibilities. Participants are expected to participate in the
total life of camp: to work, play and live together. Program Administration does not allow the use of tobacco, alcohol, illegal drugs or weapons. Registration
application signifies my understanding and acceptance of these responsibilities – violators will be dismissed without a refund. In addition, should a behavior
or discipline problem affect work with other campers or their enjoyment of Gallaudet University Youth Programs, ADMINISTRATION RESERVES THE
RIGHT TO DISMISS THOSE PARTICIPANTS RESPONSIBLE WITHOUT REFUND. In the event of withdrawal or dismissal from camp for any other reason
than illness requiring the attention of a physician, I will pay the camp fee in full. In the event I cannot be reached in an emergency, I hereby give permission
to the physician selected by the administrator to hospitalize, secure proper treatment of, and to order injection, anesthesia or surgery for my child as named
above. I will notify the Coordinator if my child has any serious restrictions related to his/her participation in the program. I also understand that the Youth
Program assumes no responsibility for accidental injury to my child during his/her stay at the camp.”
Parent Signature: ___________________________________________________ Date:___________________
College of Professional Studies and Outreach
Attn: Wendy Wiatrowski, Coordinator of Summer and Enrichment Programs
800 Florida Avenue, NE
Hall Memorial Building, Room S141
Washington, DC 20002-3695
College of Professional Studies and Outreach
Sports and Youth Camps Payment Form
I, _____________________________ , (print name of parent/guardian) give my consent for photos and/or television images of my
daughter/son, _____________________________ (print name of student) to be used for the following purposes.
1. For DC area television station or Gallaudet Cable. Initials:_______
2. For Gallaudet University publications used to advertise Youth Program in the future. Initials:_______
_______________________________________________ _________________________
Parent’s signature Date
For more information, please contact
wendy.wiatrowski@gallaudet.edu
Fax: (202) 651-5987
VP: (202) 250-2160
CPSO GU Gallaudet University
Gallaudet University • College of Professional Studies and Outreach • 800 Florida Avenue, NE; HMB S-141; Washington, DC 20002 • Tel: 202/448-7272 (tty/v) • Fax: 202/651-5987