FORM: Virtual Young Writers Society [Fall 2020]

Student Name *

First

Last

Requested program day *

(Waitlist only) MONDAY: 4th & 5th graders (3:30-4:30)
MONDAY: Middle Schoolers (4:30-5:30)
(Waitlist only) WEDNESDAY: 4th & 5th graders (3:30-4:30)
WEDNESDAY: Middle Schoolers (4:30-5:30)

Gender *

Date of Birth *

(MM/DD/YY)

Ethnicity/Race *

Special Needs

Grade for 2020/2021 school year *

School for 2020/2021 school year *

Do you participate in any of our partner programs? Check all that apply.

TGI (The Greatest Investment)
Boys & Girls Clubs
Young Life
PKZ (Parramore Kidz Zone)

Parent or Guardian Name *

First

Last

Parent/guardian PRIMARY phone number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email

PHOTO RELEASE STATEMENT

I agree to allow my child to participate in all Page 15 programs and activities and to appear in person or in voice, video or photographic presentation for radio, television, website or print media reports and/or media campaign(s) resulting from participation in a Page 15 program and/or event.

PARTICIPATION AGREEMENT *

I certify that I am the legal Parent/Guardian of the child(ren) registering and agree that I will not hold Urban Think Foundation (dba Page 15) or its representatives responsible for any injuries which may be incurred by my child in any or all activities at the program for which we are enrolling. I understand that University of Central Florida, Urban Think Foundation (dba Page 15) reserve the right to limit participation of any child for disciplinary reasons or non-payment of fees. My child is required to abide by the policies and procedures of the Urban Think Foundation and Page 15 staff.