Summer Developmental Program Form

May 29, 2007 – July 27, 2007

Complete this form only if you have been admitted to the Summer Developmental Program at Jackson State University.

Registration Form

Please Type or Print Legibly and mail to:

Dr. Marie O’Banner-Jackson
Jackson State University
JSU Box 18240
Jackson, MS  39217

_________________________________________________________________Last Name                                       First Name                           Middle Initial

_________________________________________________________________Sex                                 Social Security No.                           Major         

_________________________________________________________________
Permanent Address                       City                             State                   ZIP  

 _________________________________________________________________
Local Address                                City                             State                   ZIP

___________________________________________________________________
Parent or Guardian

_________________________________________________________________
Parent(s) Address                          City                             State                    ZIP


___________________________________________________________________
E-mail Address                                                                       Telephone No.

 

My signature below indicates that I understand that the program expectations include academic honesty, daily attendance, full participation, completion of assignments and appropriate classroom conduct.  Should I fail in any area, I should not expect to continue at a four-year institution of higher learning in the State of Mississippi.

___________________________________________________________________\

(Signature)

___________________________________________________________________
(Date)