Please print and complete this AP Summer Institute form. It should be mailed to the Center for Continued Learning, Wilkes University,  84 West South Street Street, Wilkes-Barre, PA 18766, or FAXed to the Center at 570-408-7846.

Contact Information

Registrant
First Name __________________________    Last Name __________________________

Street Address _______________________________________________

City ______________________________      State ____      Zip Code __________

Phone _________________      Fax _________________      E-mail _________________

Social Security # ________________      Date of Birth ________________

Course Number _______________    Description ________________________________

Credit ___      Audit ___

Responsible for Payment   _____ School      ____Participant

___ Ramada Double Occupancy      ___ Ramada Single Occupancy      ___ No Housing Needed

___ Hilton Garden Double Occupancy      ___ Hilton Garden Single Occupancy

___ Smoking      ___ Non-Smoking

___ Breakfast only      ___ Lunch only      ___ Meal Combination