Adult Summer Program Interest Form
Please complete this form, and submit it to indicate your interest in the Adult Summer Program at WCBVI. Classes will be held Sunday, August 4 through Friday, August 9, 2019 at the Janesville Campus. Questionnaires will be sent following receipt of this form.

WCBVI encourages persons with disabilities to participate in its programs and activities. If you anticipate needing any type of accommodation or have questions about the physical access provided, please contact us in advance so we can best meet your needs.

If you would like any assistance in completing this form or have questions, please contact:

Kathleen (Kate) Coehoorn
WCBVI Outreach Operations Associate
Phone (608) 758-6148

Your First Name *
Your answer
Your Last Name *
Your answer
Your Address, Line 1 *
Your answer
Your Address Line 2
Your answer
Your City *
Your answer
Your State *
Your answer
Your Zip Code *
Your answer
Your Email Address *
Your answer
Your Prefered Telephone Number *
Your answer
Your Other Telephone Number
Your answer
Will you be able to attend the entire one-week program? *
Have you attended the WCBVI Adult Program in the past? *
If yes, how many times? *
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