Registration Form | Quitman County Arts Council

Please fill out the form below, or click on the pdf link to download and print the form, fill it out, then bring it person or mail it to the address at the bottom of the form.

2026 QCACC - AFTERSCHOOL CAMP - REGISTRATION FORM Heading3.jpg

Name of Student

Name of School

Date of Birth required

Age

Grade

T-Shirt ($10/Optional)

Small

Medium

Large

Extra Large

Which are you applying for?

After School

Summer

Both

Name of Parent/Guardian/Primary Contact

Street Address

Apt/Unit/Ste number

City

State

Zip code

Primary Phone

Secondary Phone

Email address that you check frequently

Work Phone

EMERGENCY CONTACTS: (please provide two additional people, different from the parent/guardian listed above, who would automatically be the next we contact)

EMERGENCY CONTACTS: Please provide two additional people, different from the parent/guardian listed above, who would automatically be the next we contact.

1st Emergency Contact Name

Primary Phone

Secondary Phone

Work Phone

2nd Emergency Contact Name

Primary Phone

Secondary Phone

Work Phone

SAFETY INFORMATION: Please list all known medical or other conditions, such as, any allergies (including food allergies), or special needs the staff should know about it, in order to accomodate your camper's needs.

SPECIAL NOTE: Parents must pick up their student(s) on time, if they are not riding the District school bus.

Quitman County Arts & Cultural Center

(201 E Main Street, Marks, MS 38646)

Applications are being accepted NOW

For more information, please call (662) 205-5725

Thanks for submitting!

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