Program Participant Application

PROGRAM PARTICIPANT APPLICATION

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

First Name*

Last Name*

Nickname*

Address

City*

State*

ZIP*

Phone*

Email Address*

Annual Household Income*

School Attending in Fall 2023

Parent/Guardians Name*

Relation or Participant*

Parent/Guardian's Address

Emergency Contact Information:

Name*

Relation or Participant*

Phone Number

Additional Information

Place of Work

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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