Jackson Kappa Kamp Detailed Registration Form 2026

Registration
Directions: All forms are to be completed and returned with the application.

Early enrollment helps to ensure your child's placement in the camp(s) of your choice. We cannot guarantee admission to Kappa Kamp will be available if your fee does not accompany this form, if all forms are not completed and returned, or if you are late registering your child.
Participant Information
Is your kamper returning to Kappa Kamp?
Kamper's Name

First NameLast NameSuffix
Birth Date

MonthDayYear
Date
Age as of June 1, 2026
Social Security # (last 4)
Kamper's Address

Street Address

Street Address Line 2

CityState

Zip Code
Kamper's Phone Number

Area CodePhone Number
Kamper's Email
example@example.com
T-Shirt Size
Current Picture of Kamper

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Visitor(s)

Is there anyone who has permission to visit your child while they are at kamp?
Visitor 1 Name

First NameLast Name
Visitor 1 Phone Number

Area CodePhone Number
Visitor 2 Name

First NameLast Name
Visitor 2 Phone Number

Area CodePhone Number

Immunizations
Is the student up-to-date all immunizations?
Date of Last Tetanus or Diptheria, Tetanus, Pertussis(DTaP) Vaccine?

MonthDayYear
Date
Date of Meningitis vaccination (MCV4 or similar)- Must be within the last 5 years and done before May 28.

MonthDayYear
Date
YOUR SHOT RECORD MUST INCLUDE A CURRENT MENINGITIS SHOT (MCV4 or Similar)

Childhood immunizations are recommended from birth through 18 months, with other vaccinations possible up to 18 years of age.
Attach Immunization record: Meningitis, MMR, and Covid (may be attached as multiple files)

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General Medical History
Does your child have any food, medication, or environmental allergies?
Alergies? Check all that apply
Please list and explain any allergies.
Significant Medical History (surgery, injuries, serious illness):
List any Medical Conditions (asthma, seizures, headaches, ADHD):
Will you be sending medication?
List any medication taken and how often it must be taken: (including allergy medication)
In an emergency does this child require additional assistance (more than other children of the same age or in the same group) to evacuate?
Please describe
I consent to the following administration: sunscreen - topical product or lotion, exact dosage: liberal application per exposed area, to be administered: before high sun exposure.
Physical Examination
Height:
Weight:
Eye Color:

Consent to Student Drug & Alcohol Testing

I, the undersigned camper, acknowledge that I am not a drug or alcohol user. I understand that, upon my acceptance as a summer camper at the Kappa Kamp Summer Enrichment Camp in Mississippi. I may be tested if school or camp officials have reasonable suspicion of drug and/or alcohol use. I agree to comply with the rules and regulations of the college’s Summer Enrichment Camp regarding drug and alcohol use. If, upon reasonable suspicion by school officials, I am tested for drug and or alcohol use, I hereby authorize the confidential release of the results of the testing to Paul Quinn College’s summer camp director, to my parents or guardians, and other designated school officials as necessary.
Student Name

First NameLast Name
Student Signature
Consent and Endorsement of Parent/Guardian

We, the parents or legal guardians of the above camper, hereby acknowledge that we understand Kappa Kamp's Student Drug and Alcohol Testing Policy and consent, upon reasonable suspicion by school officials, to the testing, by urinalysis or alcohol/breath test, of our child, and agree to the confidential release of the test results.
Parent/Legal Guardian 1 Signature
Parent/Legal Guardian 2

First NameLast Name
Parent/Legal Guardian 2 Signature

Confirmation

By acknowledging and signing below, I am delivering an electronic signature that will have the same effect as an original manual paper signature. The electronic signatures will b equally as binding as an original manual paper signature. I have read the campus brochure and understand its contents. My child and I agree to abide by the guidelines governing this program.
Participant Acknowledgement and Release Pages

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Parent/Legal Guardian Signature
Date

MonthDayYear
Date

Kappa Kamp Registration$750.00

Enter coupon

Total $0.00

Registration