Summer Camp 2026 Registration

Child Information

Please fill out this section as COMPLETELY and accurately as possible. If you have multiple children, you may use the Child 2 and 3 sections, or leave blank if not needed.

An incomplete application may prevent your child from being accepted into the Summer Camp Program!

Child 1 Name

Child 1 Date of Birth

Child 1 Age

Child 1 Gender

Child 1 Tshirt Size

Child 1 School Attended in 25-26 School Year

Child 1 School Attending in 26-27 School Year

Child 1 Entering Grade

Child 1 Swimming Ability

List any known allergies of your child. If none type "NONE"

Child 2 Name (First and Last)

Child 2 Date of Birth

Child 2 Age

Child 2 Gender

Child 2 Tshirt Size

Child 2 School Attended in 25-26 School Year

Child 2 School Attending in 26-27 School Year

Child 2 Entering Grade

Child 2 Swimming Ability

List any known allergies of your child. If none type "NONE"

Child 3 Name (First and Last)

Child 3 Date of Birth

Child 3 Age

Child 3 Gender

Child 3 Tshirt Size

Child 3 School Attended in 25-26 School Year

Child 3 School Attending in 26-27 School Year

Child 3 Entering Grade

Child 3 Swimming Ability

List any known allergies of your child. If none type "NONE"

Parent/Guardian Information

Please fill out this section as COMPLETELY and accurately as possible. Parent/Guardian 2 can be left blank if not needed. If more than one parent is listed, please list the MAIN Contact FIRST.

Parent/Guardian 1 Name (First and Last)

Parent/Guardian 1 Home Address

Parent/Guardian 1 Cell Phone Number

Parent/Guardian 1 Email

Parent/Guardian 1 Place of Employment

Parent/Guardian 2 Name (First and Last)

Parent/Guardian 2 Home Address

Parent/Guardian 2 Cell Phone Number

Parent/Guardian 2 Email

Parent/Guardian 2 Place of Employment

Pickup and Emergency Contact Info

Please fill out this section as COMPLETELY and accurately as possible. This is who we will contact if there is an emergency or change in schedule and we are unable to reach you. Your child will not be released for pickup to any adult not listed on this form (can be updated in writing if changes need to be made later)

Primary person responsible for signing your child in and out (First And Last Name)

Their Phone Number

Relationship to your child (mother, father, grandmother, aunt, etc.)

Any other approved people allowed to sign your child in and out (NOTE: ALL APPROVED MUST BE OVER 18 YEARS OLD). Please type name, phone number, and relation to the child for EACH approved person. If none, type

Emergency Contact 1 (First and Last Name)

Emergency Contact 1 Phone Number

Emergency Contact 1 Relationship to your child (mother, father, grandmother, aunt, etc.)

Emergency Contact 2 (First and Last Name)

Emergency Contact 2 Phone Number

Emergency Contact 2 Relationship to your child (mother, father, grandmother, aunt, etc.)

E-Signature Agreement

I agree and understand that by completing this application that all electronic signatures (typed legal name) are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. I further agree my signature on this document is as valid as if I signed the document in writing.

I agree

Type Full Name

Today's Date

Financial Agreement

I understand that JVMPF Summer Arts Camp will not provide services until payment is accepted. I understand that payment for JVMPF Summer Arts Camp will be made via cash (EXACT AMOUNT) or credit/debit card. No other forms of payment will be accepted. I understand that payments are due weekly on Monday morning when the child is dropped off at camp. Payments will be accepted earlier (for example, the Friday before) but no later than Monday morning. I understand that my child may be suspended from JVMPF Summer Arts Camp in the event that my credit/debit card company nor I make payment. I understand that it is my responsibility to pay each week on time. I understand that my payments are non-refundable.

I agree

I understand that Pickup for JVMPF Summer Arts Camp closes each day at 5:00 PM. In the event that my child is picked up after 5:00 PM, I understand a late fee of $5 per five minutes is due and payable to the late duty staff.

I agree

E-Signature (Type Your Full Name)

I would like to be contacted about the possibility of my child receiving a scholarship (if not needed, skip the next question) PLEASE NOTE THAT SCHOLARSHIPS ARE LIMITED AND EVERY CHILD WHO APPLIES MAY NOT RECEIVE A SCHOLARSHIP

Yes Not Needed

IF approved for a scholarship, what amount could you contribute for your child's weekly tuition (regular tuition is $75 per week)? Type an amount between $0-$75

Medical Release and Authorization

If a parent or legal guardian cannot be contacted during the time of emergency, the undersigned parent/legal guardian authorizes a representative of John & Vera Mae Perkins Foundation to give consent to X-ray, anesthetic, or surgery if the need arises. I certify by my e-signature below that I have read, understand, and give consent to all the statements contained in this authorization.

E-Signature (Type your Full Name)

List any special medications your child takes. If none type "None"

Name of Family Physician

Insurance Carrier

Phone Number of Family Physician

Release and Waiver of Liability

This Release and Waiver of Liability (the "Release") is executed on this day of 2025, by the parent/guardian of the child participating in activities at the John & Vera Mae Perkins Foundation ("the Foundation"), a nonprofit organization based in Mississippi, USA. This Release covers the Foundation, its affiliated organizations, directors, officers, employees, and agents.

Permission to Participate
I grant permission for my child to take part in activities at the John & Vera Mae Perkins Foundation, which may include travel, food consumption, and light work projects on the Foundation’s grounds. I understand these activities are designed to be enriching and safe.

Terms of Release
1. Waiver of Liability – I release and hold harmless the Foundation from any legal claims, liabilities, or demands related to my child’s participation.

2. Insurance – I understand that unless otherwise agreed in writing, the Foundation does not provide health, medical, or disability insurance coverage for participants.

3. Medical Treatment – In case of an emergency, I release the Foundation from any claims related to first-aid or medical treatment given to my child during their participation.

4. Assumption of Risk – I acknowledge and accept the potential risks of injury, illness, or property damage associated with my child’s participation in Foundation activities.

5. Photographic Release – I grant permission for the Foundation to use photographs, videos, or audio recordings of my child taken during activities, including any benefits derived from them.

6. Legal Agreement – This Release is intended to be as inclusive as permitted by Mississippi law. If any part of this document is deemed invalid, the rest remains enforceable.

By signing electronically, I confirm that I have read, understand, and agree to the terms of this Release.

E-Signature (Type your Full Name)

Summer Camp Agreements & Expectations

Please click "I agree" after each statement to show that you have read it, understand, and agree to the expectation

LOST, DAMAGED, OR STOLEN ITEMS: I understand that The Perkins Foundation is not responsible for any items that are lost, damaged or stolen at Summer Camp. Please mark your children’s names in all clothing, backpacks, swimsuits, towels, etc. Students are not allowed to bring toys, phones, or any electronics. If seen, they will be held by Perkins staff until time of dismissal. I understand that I am responsible for any damages my student deliberately causes to Perkins Foundation property and facilities.

I agree

EXPECTED BEHAVIORS: I understand that The Perkins Foundation may temporarily suspend or terminate my student’s enrollment for any of the following reasons: behavior that is disobedient, obstinate, disrespectful, violent, or dangerous to others and/or self; bullying in any form will not be allowed; behavior that is destructive to property and/or refusal to replace said property; harassment, violent behavior or threat of such behaviors against a staff person or other member by parent/guardian or persons associated to the student (family member, family friend, etc.).

I agree

EXPECTED BEHAVIORS, CONTD: I understand that Perkins staff do not allow students to hit or hit back, nor are student allowed to take matters into their own hands. My student is to bring disputes to Perkins staff, who will handle each situation in accordance with Perkins rules/guidelines.

I agree

PICKING UP STUDENTS: I understand that if a student's behavior causes them to be suspended from Summer Camp (or if the student needs to be sent home due to illness) an adult must come to retrieve the student within 30 minutes of receiving the call, or further suspension will be granted.

I agree

STUDENT HEALTH: Campers may not attend camp with a fever. Any child who has been nauseated or who has vomited during the evening should not be in camp the following day. Children must be fever free with no vomiting or nausea for 24 hours to return to camp.

I agree

UPDATING CONTACT INFORMATION: I understand that if the primary caregivers or anyone on the student’s pick-up list’s phone number changes during the duration of Summer Camp, it is their responsibility to inform staff to ensure effective communication.

I agree

Parent Manual

PARENT MANUAL: All parents must read and agree to abide by the Summer Camp Parent Manual. (Click link to access)

I have read and agree to abide by the Summer Camp Parent Manual

I agree

Summer Camp 2026 Registration

Description

Please Fix the Following