College for Kids 2024 Registration Form

By completing and submitting this form, you are granting full permission for your child to participate in the DSCC College for Kids program.

Section I: Participant/Child Information

Student/Participant Name:
Birthdate:
Address:
City:
State:
ZIP:
Country:
School grade during 2024/2025 school year:
T-Shirt Size:

Are there any medical conditions/allergies that we need to be aware of?

Yes
No

If yes, please explain here:
If the condition or allergy requires an accommodation, please list details here:

Section II: Parent/Guardian Information

Name:
Relation to student/participant:
Address:
City:
State:
ZIP:
Country:
Email Address:
Phone Number:
Emergency Contact Name:
Emergency Contact Phone Number:

Dyersburg State Community College (DSCC), pursuant to the Tennessee Personal Rights Protection Act of 1984, has permission to use the name, photo/video images, voice recordings and other characteristics making up the likeness of your child, who is under the age of 18 years, for promotional purposes as they see fit, unless you, as the parent or legal guardian, opt out. Therefore it is understood that no compensation will be made for allowing DSCC to use his/her name and/or likeness.
Initial to Opt Out:

Section III: Course Choices

Select your desired location:

Select your primary class options:

Class Choice 1:

Class Choice 2:

Class Choice 3:

Select one alternate class:

Alternate Class 1: