JJSC 2022 Registration Form

Welcome to JUMPIN' JAMBALAYA Summer Program 2022 at the African American Cultural Center

Fill out the form carefully for registration
Child's Name *

First Name Middle Name Last Name
Birth Date

Month Day Year
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Name

First Name Last Name
Relationship to Child
Address (if different from above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
E-mail
example@example.com
Phone Number

Area Code Phone Number
Emergency contact name

First Name Last Name
Phone Number

Area Code Phone Number
Child's School
Grade
Teacher
Requirements:
ALL PARENTS MUST PROVIDE A COPY OF THEIR CHILD'S REPORT CARD FOR ALL CLASSES:
Should be Empty:

Welcome to JUMPIN' JAMBALAYA Summer Program 2022 at the African American Cultural Center