Summer Jam Registration
June 11-August 3rd 9:00am - 12:00pm
Resurrection Assembly of God
1330 Keokuk Street
Summer Jam is a free summer program for any kid or teen under the age of 18.
Free breakfast & lunch will be provided on site, as well as educational activities, and community workshops.
Children younger than school age (K-12) must be accompanied by an adult or responsible older sibling/student.
All are welcome.
Email address *
Student Information
Student Name (First, Last) *
Your answer
What grade will your student be going into next year?
Medical Concerns? *
Your answer
Allergies? *
Your answer
Any Other Pertinent Information?
Your answer
Parent/Guardian Information
Parent/Guardian Name (First, Last) *
Your answer
Parent/Guardian Phone *
Your answer
Your answer
Emergency Contact
Emergency Contact Name (First, Last)
Your answer
Emergency Contact Phone (First, Last)
Your answer
Do We Have Permission To Post Pictures Of Your Student On Social Media? *
In the case of an emergency do you give our staff/volunteers permission to seek appropriate medical help for your student? *
Do you have a preferred hospital?
Your answer
If at any point staff/volunteers deem it necessary for your student to go home (illness, behavior issues, etc.) it is your responsibility to pick them up, or give them permission to walk home. Do you understand and agree to these terms? *
Does your child have permission to walk home? *
If you have any questions please contact Abby Anderson at 319-333-6687 or at
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