Student Application

Note: Required fields are marked with a red asterisk, and The Mississippi Prep will receive data exactly as it is entered. Please be careful of spelling, capitalization, and punctuation.

Student Information
First Name

Last Name

Contact Number

Gender

Previous School Name

Grade

GPA

ACT Score

DOB

Full Street Address

Who has offered you [previously]?

Colleges in which you are interested in attending:

NCAA ID Number

I provided my NCAA ID Number. I currently do not know or do not have an NCAA number. I understand my NCAA number must be provided for all NCAA student reporting purposes prior to the completion of the program.

Student Medical Release Information
Name of Health Insurance Provider:

Policy Number

Primary Physician

Address

Phone Number

Hospital Preference

I understand individual Health Insurance is mandatory.

Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures)
The purpose of this information is to ensure that medical personnel has details of any medical problem which may interfere or alter treatment.

Required Treatment?

Should paramedics be called?

Is the above student presently being treated for an injury or sickness, or taking any form of medication for any reason?

If the above answer is yes, please explain.

Is the above student allergic to any type of food or medication?

If the above answer is yes, please explain.

Does the above student require a special diet?

If the above answer is yes, please explain.

Parent/Guardian Information
Parent/Guardian #1
First Name

Last Name

Contact Number

Full Street Address

Occupation

Employer

Parent/Guardian #2
First Name

Last Name

Contact Number

Full Street Address

Occupation

Employer

Emergency Contact Information
Contact #1
First Name

Last Name

Cell Number

Relation to student:

Contact #2
First Name

Last Name

Cell Number

Relation to student:

Contact #3
First Name

Last Name

Cell Number

Relation to student:

Terms of Agreement

I understand that I am reasonable for all injuries related to my child, and will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event myself/child is injured or becomes ill. I understand that The Mississippi Prep will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as the student, or parent/guardian. I understand all payments are final, and The Mississippi Prep does not offer any money-back guarantees. You recognize and agree that you shall not be entitled to a refund for any payments.

Photo Release

I hereby give permission for myself/the student to be photographed during The Mississippi Prep events. I understand the photos will be used to keep a journal of activities, to share during PowerPoint presentations/or reports to our donors, and for promotional purposes including flyers, brochures, newspapers, and on the internet. I understand that although my photographs may be used for advertising, his/her identity will not be disclosed, I do not expect compensation, and that all photos are the property of The Mississippi Prep and its affiliates.

Transportation Release

I hereby give permission for the transportation of myself/student for official The Mississippi Prep activities by modes of transportation agreed to by staff and administrators. The Mississippi Prep and its co-organizers are not responsible for lost or damaged personal property and all scheduled events and are subject to change. [Initials]

The Mississippi Prep Hurricanes

The Mississippi Prep Hurricanes

One Goal | One Mission | Ultimate Success

Proverbs 16:3

Student Application

Note: Required fields are marked with a red asterisk, and The Mississippi Prep will receive data exactly as it is entered. Please be careful of spelling, capitalization, and punctuation.

For application to be processed, please click button to pay $25.00 application fee.

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