JPS 3rd - 5th Grade Summer Music Camp

Jackson State University 3rd-5th Jackson Public Schools Grade Summer Music Camp

Fields with asterisk are required.

School *
What is the current grade level of your child? *
What will be the grade level of your child for the 2025-2026 school year? *
Student's First Name *
Student's Last Name *
Address *
City *
State *
Zip Code *
Ethnicity
Gender *
Date of Birth *
Does your child receive exceptional education services? *
Parent's First Name *
Parent's Last Name *
Phone Number *
Email Address *
Sign Out Information and Emergency Contact 1
First Name
Last Name
Primary Phone Number
Relationship
Sign Out Information and Emergency Contact 2
First Name 2
Last Name 2
Primary Phone Number 2
Relationship 2
Does your child have medical insurance? *
Is there a preferred hospital to use in case of an emergency?
Are there any medical conditions of which the Summer Camp staff should be aware? Any known allergies
I have read and understand the above. By typing my name, I approve my child's camp participation. *

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2025 Jackson State University
3rd-5th Jackson Public Schools Grade Summer Music Camp

This application must be complete for each scholar to participate in the 3rd-5th Grade Summer Music Camp. This camp is open only to Jackson Public Schools students.

Sign Out Information: Safety is a top priority for Jackson State University, therefore, a student enrolled in the program will not be released without a parent or guardian signature or that one of one of the two individuals listed below, if the parent/guardian cannot be reached.
Note: The names listed as emergency contact must be someone 18 years or older.