Project Rise Summer Program 2026 Application

This form does not guarantee enrollment in our summer camp program. Please wait for a representative from Operation Shoestring to confirm your child(ren)’s enrollment. Please note that enrollment for students attending Walton and Galloway Elementary who are not currently Operation Shoestring students will open on March 16th. Students within the Lanier Feeder Pattern who are not currently enrolled in Operation Shoestring will be able to apply starting April 7th. Afterwards, Hinds County residents attending a public school will be able to apply starting April 27th. Space is limited.

Student Information

Today's Date(Required)

Has your child enrolled in our program before?(Required)

Yes

No

If yes, when?

Child's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone(Required)

Social Security Number(Required)

Child's MSIS Number

Birth Certificate(Required)

Max. file size: 512 MB.

Please upload a copy of the child’s birth certificate.

Race

Sex(Required)

Date of Birth(Required)

Age(Required)

School(Required)

Walton Elementary

Galloway Elementary

Johnson Elementary

Lanier Jr/Sr High School

Powell Middle School

Other–Please enter below.

Enrollment in these schools will be verified.

Grade in August 2026(Required)

Please write in your child's school here if not listed above. Please note that only residents of Hinds County enrolled in a public school will be admitted.

Clothing Size(Required)

Shoe Size(Required)

Parent/Guardian Information

Parent/Guardian Name(Required)

First Last

Email(Required)

Social Security Number(Required)

Date of Birth(Required)

ID of Parent/Guardian(Required)

Max. file size: 512 MB.

Please upload a copy of the parent/guardian’s ID.

Race

Sex(Required)

Marital Status(Required)

Head of Household(Required)

Education Level Completed(Required)

Do you have insurance?(Required)

Yes

No

Insurance Provider

Policy Number

List all persons living in the household.(Required)

Include Name, Relationship to Child, Age, and Enrollment Status.

Are you employed?(Required)

Yes

No

If yes, who is your employer?

Employer's Phone Number

Employer's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Income Information

How often do you currently receive income?(Required)

Weekly

Twice Monthly

Monthly

Annually

Amount Received(Required)

Name of Employer for Any Other Individual Living in the Home

Please include individual’s name, employer’s name, employer’s address, employer’s phone number.

List the Type and Amount for Any Other Sources of Income

Please include Child Support, TANF, Social Security, Unemployment, Food Stamps, Utility Check/HUD, Disability, Pension/Retirement.

Proof of Income(Required)

Max. file size: 512 MB.

Please upload proof of income.

Child's Name

First Last

Emergency Contact

Please list individuals to be notified in an emergency situation other than the parent/guardian. Include Name, Relationship to Child, and Phone Number. The above persons may also pick up the child from Operation Shoestring. I understand that the persons listed must present proper identification if requested.

Consent

Child's Name

First Last

Parent/Guardian's Name

First Last

A separate permission slip is required for each field trip. Should there be an occasion for children to walk to and/or from Galloway, Operation Shoestring and/or a satellite location: All children will walk under the direct supervision of Operation Shoestring staff. At each street crossing a staff person will verify that oncoming traffic is aware of the intended crossing and have come to a complete stop. Before signaling for children to cross, staff will post a crossing guard holding a stop sign in front of the stopped traffic. One staff person will be first to cross and another will be last to cross at the end of the group.

Date

Critical Medical Information

Please list any medical or emotional conditions that your child has that the center staff should be aware of.

Physician's Name(Required)

Physician's Phone Number(Required)

Preferred Hospital

Insurance Provider

Policy Number

Parent Handbook Acknowledgement

I have received a copy and read the Parent Handbook for Operation Shoestring Project Rise(Required)

Yes

I understand and agree to Operation Shoestring Project Rise Parent Handbook policies and procedures as it is stated.(Required)

Yes

I understand Operation Shoestring Project Rise Photography/Video consent.(Required)

Yes

I agree and give consent to allow Operation Shoestring to contact any persons listed for Pick-up, Emergency Notification and give Emergency Medical Treatment.(Required)

Yes

I understand and agree to Operation Shoestring Car Rider Policy, permission for Field Trips and Transportation Policy.(Required)

Yes

Transportation Information

Dear Parents, Our after-school students are transported to Operation Shoestring from Galloway Elementary School as both a courtesy and expense of the Jackson Public School District. It is imperative that we respect their generosity and the terms of our transportation agreement. Therefore, we must comply with the same rules and regulations that Jackson Public Schools enforce for all of its bus riders. This means the following: – Students who are suspended from the bus will be suspended from our program for the same number of days. – Any student that causes habitual behavior on the bus will be suspended from the after-school program. The student will then be required to get home by whatever means were established with the school system upon their enrollment in Galloway Elementary School. – If a student’s behavior becomes disrespectful, disruptive, or dangerous for himself/herself, the driver, Operation Shoestring staff, or other students, he/she will be suspended from the after-school program. We thank you in advance for your cooperation regarding this matter and look forward to peaceful, pleasant bus rides for the remainder of the school year. Please check the box below to indicate that you understand and support our efforts to maintain our transportation relationship with the Jackson Public School District. Sincerely, Lakesha Partee, Program Coordinator Operation Shoestring, Inc.

Child's Name

First Last

Child's Grade Level

Date

Post Custom Field

Email

This field is for validation purposes and should be left unchanged.

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