BHSA Registration Form

Black History Summer Academy 2025 Registration

Hosted by Drury University- Lay Hall

900 N. Benton Ave Springfield, MO 65802

Monday, June 9, 2024 - Friday, June 13, 2024

6:00pm-8:30pm

Deadline is Saturday, June, 1, 2024

For more information: Contact-Gwen Marshall

417-523-0008
Name

First NameLast Name
Grade Level - Please select one:Kindergarten1st-2nd3rd-5th6th-8th9th-12thAdultOther
If registrant is younger than 18 years old what is the parent or guardian's name?
Name

First NameLast Name
My son/daughter has my permission to participate in the activities at the Black History Summer Academy. I give my child permission to be transported for activities sponsored by Black History Summer Academy. I will not hold the Black History Summer Academy, any of its officers and volunteers, the host site, or the sponsors liable in any case of accident or emergency.
Parent or Guardian Signature

Clear
Address
City, State Zip Code
Phone Number
Shirt Size (Youth: S-XL or Adult S-3XL)
Email
example@example.com
The following information is needed in case of an emergency:
Name
Phone
Name
Phone
Name
Phone
Please list any medical or allergy issue that could occur during Black History Summer School