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UNITAS Weekend Application

UNITAS Pre Orientation Weekend
Registration Form
Friday, July 12, 2013 - Sunday, July 14, 2013

Application Deadline:
Thursday, June 27, 2013
Weekend Registration: $100
Non Refundable

AAP & STOVS STUDENTS
CLICK HERE TO REGISTER

Please complete this form. When you click the Submit Button, you will see a confirmation form, click PAY ONLINE to go to our secure online payment site to pay by credit card. Your registration is NOT COMPLETE until the online payment is completed and the parental waiver faxed to our office. Print a copy for your records.

Please download this Parental Consent Waiver, complete, sign and FAX to our office...610-519-7758.

Personal Information

First Name:

Last Name:

Gender:

Permanent Address:

Phone:

Cell:

Email:

Intended Major:

Allergies:

Medical Conditions/Medications

Emergency Contact Information

Parent/Guardian:

Address:

Daytime Phone:

Nighttime Phone:

Family Physician:

Physician Phone:

Additional Information

Favorite Movie:

Favorite Color:

Favorite Food:

Favorite Musician:

Theme Song of Your Life:

Would you like your contact info added to the weekend contact list?

Yes No

Name on Credit Card
you will be using:

Payment Amount $:

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