Young Futurists Project 2025-26 After-School Registration Form

JMMF 2025-26 Young Futurists Project After-School Registration

350 W. Woodrow Wilson Ste. 3504, Jackson, MS 39213
Limited Slots Available

Ages 13-18 | In-person | Starts August 12th
Free for all Jackson Public School Students & SNAP & TANF Receipients

Fee of $75, if you live outside of the area per month | Limited Scholarships, will be available

Transportation is provided at the surrounding schools in the area: (Powell Middle School, Murrah High School, and Lanier Jr./ Sr. High School, & Bailey APAC)
How did you hear about us?
Participant Information
Student Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Participant Social Security Number (Last four (4) digits)*
Student's Cell Number
Please enter a valid phone number.
Age*
School Grade (2025-2026)*
School Name*
Are you a Snap or TANF recipient?*

YESNo
What is your total annual income?

$0 to $20,000$21,000-$49,999$50,000-$89,999$90,000+
SNAP or TANF Case number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list all known medical and Allergies conditions
Please list all known physical limitations, behavioral concerns, or other important information about your child.
Parent/ Guardian Information
Name*

First NameLast Name
Mobile Number*
Work Number
Home Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
1. Name*

First NameLast Name
Relation to Participant*
Cell Number*
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Is this person allowed to pick-up your child?*

YESNO
2. Name

First NameLast Name
Relation to Participant
Cell Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Is this person allowed to pick-up your child?

YESNO
COVID-19 Precautions

The COVID-19 policy below will be enforced if there is a spike in Covid-19 cases, however, it is the parent's discretion if they would like their scholars to wear a mask daily. Nevertheless, until then the policy is NOT enforced currently.
Will your child be willing to follow all safety protocols including: wearing a mask if needed, having your temperature checked as you enter, utilizing hand sanitizer, and social distancing? (*If*

YESNO
Are you willing to get your child Covid-19 tested before school starts, and periodically throughout the semester, if needed?*

YESNOMAYBE
Has your child been vaccinated?

YESNO
Parent Participation
Are you willing to participate in parent orientation, engagements, and workshops?*

YESNOMAYBE
Are you interested in our in-person program for 13-18 years old?

YESNO
Are you interested in our Virtual Tutoring for ages 8-18?

YESNO
Permission to Participate

INFORMED CONSENT FOR PARTICIPATION AND WAIVER OF LIABILITY
I, blanks being the parent/legal guardian ofblank* a minor, do hereby consent to his/her participation in Young Futurists Project youth program sponsored and/or organized by Jackson Medical Mall Foundation. I consent for my child to participate in programs offered through Jackson Medical Mall Foundation’s Young Futurists Project (YFP) such as robotics, virtual reality, coding/programming, artificial intelligence, strategic foresight/futurism, hackathons, arts & crafts, youth advocacy/public policy, counseling, culture of health/health equity, teen pregnancy prevention, health and wellness activities, mental health assessments, and soft skills training, including communication and the use of social media to promote the YFP program on social media accounts run by JMMF. I understand that he/she is responsible for his/her behavior and will only perform volunteer work or participate in activities that he/she is comfortable doing. Having read this waiver and knowing these facts and in consideration for the acceptance the above-named minor’s participation in YFP organized and/or sponsored projects, events, and programs, I do hereby waive and release YFP, the sponsors, their staff and all persons directly or indirectly related to the program of any project my son/daughter works on, from any and all claims that may arise as a result of any expenses, personal injury, loss or damages incurred by my son/daughter during his/her participation in a YFP youth program. I understand the staff is trained in first aid and CPR and I authorize them to give my child first aid and CPR when staff deems it appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child.
Participant's Name *

Clear
Parent/ Guardian Signature *

Clear

Media Release for Children and Dependents

Parent/Guardian
I, Parent/Legal Guardian of (child’s name) blanks hereby grant permission to the Jackson Medical Mall Foundation (JMMF) and its assignees and licensees to take photographs or videos of the above named minor child or dependent adult, and to make recordings of the above named minor child’s or dependent adult’s voice as indicated below: (Please check one choice in the blank.) I DENY permission to JMMF to use my child’s image or voice recordings in any manner. I GRANT permission for JMMF to use my child’s image and voice recordings in the following manners:

Unrestricted usage: I give unrestricted permission for images, videos, and recordings of my child or dependent to be used in print, video, digital, internet, and media. I agree that these images and/or voice recordings may be used by for a variety of purposes and that these images may be used without further notifying me. I understand that uses of the images, videos and recordings will be in alignment with JMMF publication standards.

This release expresses the complete understanding of the parties.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

JMMF 2025-26 Young Futurists Project After-School Registration

Limited Slots Available

Participant Information

Parent/ Guardian Information

Emergency Contact

COVID-19 Precautions

Parent Participation

Permission to Participate

Media Release for Children and Dependents