Camp Signup 2018

Please complete this registration form or fill out the print form and fax to Sharon King at (601) 266-6075. You may also submit payment and registration through mail to the address listed at the end of the application. Once we receive it, we will send you specific information about the program, including directions to the Eagle Maker Hub.

One-Day camps are on Thursdays from 9am to 3pm. Two-day camps are Monday and Tuesday from 9am to 3pm. Bring your own sack lunch for each camp day.

Dates for Camps

Please select the camps you would like to attend.


Participant Information

Participant Name:

Shirt Size:

Method of Payment:

Make check out to Eagle Maker Hub. Please list name of camp on check or mailed application.


Participant Personal Information

Date of Birth (mm/dd/yyyy):

Presently enrolled at

Grade in Fall 2018:


Parent(s) or Guardian(s) Contact Information

Parent(s) or Guardian(s) Name:

Mailing Address:

Street:

City:

State:

Zip:

Phone Numbers (provide at least one):

Father:

Mother:

Guardian:

In case of emergency, contact:

Email Address:

To the Parents or Guardians of the Participant

For your child to receive medical care in the event of illness or injury while participating in the USM event, we ask that you bring a copy of all relevant insurance information for your child with you to the event. We will store it securely until the end of the program, where we will then return the copy to you.

Is it permissible to provide medical treatment for your child if needed?

Please state any special medical conditions that may require staff attention:

Does your child take medication on a regular basis of which we need to be aware?

If yes, please explain:

Does your child have any known allergies?

If yes, please explain:

Is your child under the care of a psychologist/psychiatrist, or being treated for any emotional or mental issues?

If yes, please explain:

Are there any restrictions of physical activity that may apply to your child?

If yes, please explain:


I certify that my child has permission to attend the Eagle Maker Hub Camp event at USM's Eagle Maker Hub.

I release USM from any and every liability, claim, right of action of any kind or nature which my child or legal representative may have for any and all bodily or personal injuries or property damages or any other damages resulting there from which might occur during participation in this program and host institution(s), or representative(s) thereof, and the management or owner(s) of any physical facility in which the program is conducted.

Parent or Legal Guardian's Name:

Parent or Legal Guardian's Signature (Type in signature.):

Date signed (mm/dd/yyyy):

Send payment to:
Sharon King
Eagle Maker Hub
Univ. of Southern Mississippi
118 College Drive #5018
Hattiesburg, MS 39406-0001