Clone of Young Futurists Project 2025 Summer Experience Registration Form

JMMF 2026 Young Futurists Project Summer Experience Registration

Participant Consent Form
Limited Slots Available

Starts June 1st | 7:30 a.m. - 3:30 p.m | Ages 8-18 | In-person
Free for all Jackson Public School Students

Registration fee of $185 if you do not attend JPS or not a SNAP or TANF Recipient
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.Format: (000) 000-0000.
Age*
School Grade (2026-2027)*
School Name*
YESNo
SNAP or TANF Case number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list all known medical, allergies or food allergies conditions, if none please put N/A *
Please list all known physical limitations, behavioral concerns, or other important information about your child.
Parent/ Guardian Information
Name*

First NameLast Name
Mobile Number*
Format: (000) 000-0000.
Work Number
Format: (000) 000-0000.
Home Number
Format: (000) 000-0000.
Email*
example@example.com
Emergency Contact
1. Name*

First NameLast Name
Relation to Participant*
Cell Number*
Please enter a valid phone number.Format: (000) 000-0000.
Work Number
Please enter a valid phone number.Format: (000) 000-0000.
YESNO
2. Name

First NameLast Name
Relation to Participant
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Number
Please enter a valid phone number.Format: (000) 000-0000.
YESNO
Recommendation

List One Reference -Name & Email address (Must be a Principal, Teacher or Counselor)
Name*

First NameLast Name
Email Address*
Parent Participation
YESNOMAYBE
COVID-19 Precautions

*Will be enforced, if necessary*
YESNO
YESNOMAYBE
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 or organizations/companies 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 *
Parent/ Guardian Signature *

Media Release for Children and Dependents

Parent/Guardian
I,   First Name   Last Name   Parent/Legal Guardian of (child’s name) 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 for the research or promotion of JMMF programs, events, and services: (Please check one choice in the blank.)

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.

      I GRANT permission for JMMF to use my child's image and voice recordings in the manners listed above.

I DENY permission to JMMF to use my child's image or voice recording in any manner.

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.Format: (000) 000-0000.
Signature*
Date

MonthDayYear
Date
Should be Empty:

JMMF 2026 Young Futurists Project Summer Experience Registration

Limited Slots Available

Free for all Jackson Public School Students

Participant Information

Parent/ Guardian Information

Emergency Contact

Recommendation

Parent Participation

COVID-19 Precautions

Permission to Participate

Media Release for Children and Dependents