Program Participant Application

2019 Participants Contract and Parental Consent Form.

Legal name of participant (must match BIRTH CERTIFICATE). For additional questions please contact us at 618-274-5437.

BRING IN PRINTED AND SIGNED WAIVERS TO THE JACKIE JOYNER KERSEE CENTER TO COMPLETE REGISTRATION. IF YOU CAN NOT PRINT THE BELOW WAIVER COME INTO THE CENTER TO COMPLETE REGISTRATION FOR DESIRED PROGRAM(S).

Click here for a PRINTABLE APPLICATION FORM

Program Participant Application

Program Applying For*
First Name*
Last Name*
Nickname
Address*
City*
State*
ZIP*
Phone*
Email Address*
Gender*
Shirt Size*
Race*
Annual Household Income*
School Attending in Fall 2021*
Grade Level in the Fall 2021*
New or Returning Member*
Parent/Guardian’s Name*
Relation to Participant*
Parent/Guardian’s Address*
Emergency Contact Information:
Name*
Relation to Participant*
Phone Number*
Additional Information
Primary Source of Income*
Employment Status*
Place of Work
Marital Status*
Transportation*
Important Disclosures
Click here to print the 2018 Parental/Guardian Permission and Waiver document and Student Records and Shared Agreement Contract

BRING IN PRINTED AND SIGNED WAIVERS TO THE JACKIE JOYNER KERSEE CENTER TO COMPLETE REGISTRATION. IF YOU CAN NOT PRINT THE ABOVE WAIVER COME INTO THE CENTER TO COMPLETE REGISTRATION FOR DESIRED PROGRAM(S).
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Program Participant Application

Program Participant Application

Program Participant Application

Emergency Contact Information:

Additional Information

Important Disclosures

Help our kids win in life!

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