Student Name *

First Name

Last Name

Gender *

This question is required by some of our funders. We recognize that this is a binary question, but this is the language of our funders at present. Please select the option that best fits how your child identifies or presents day to day. If neither M nor F fits, select "I'd rather not say."

Male

Female

I'd rather not say

Date of Birth *

MM

DD

YYYY

Have you participated in 916 Ink before? *

Yes

No

Which of the following best describes the participant's race or ethnicity *

American Indian or Alaska Native

Asian

Black or African-American

Hispanic or Latino

Native Hawaiian or Pacific Islander

White

Decline to state

What language is spoken most of the time at home? *

(select one)

English

Spanish

Russian

Ukrainian

Laotian

Vietnamese

Hindi

Chinese

Hmong

Tagalog

Decline to state

Home Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Phone #1 *

(###)

###

####

Parent/Guardian Phone #2

(###)

###

####

Emergency Contact #1 *

First Name

Last Name

Emergency Contact #1 *

(###)

###

####

Emergency Contact #2

First Name

Last Name

Emergency Contact #2

(###)

###

####

Authorized Person(s) to Pick-up Students

First Name

Last Name

Phone #

(###)

###

####

First Name

Last Name

Phone #

(###)

###

####

List anyone who specifically cannot pick up your child

First Name

Last Name

Phone #

(###)

###

####

First Name

Last Name

Phone #

(###)

###

####

Release of Liability *

I agree to release and discharge in advance the 916 Ink officers, employees, agents and contractors from any and all liability for personal injury, death or property damage connected with my participant(s). This release shall remain in effect until revoked in writing. I also assume full responsibility for the above child's behavior and agree to pay for damages to property or persons caused the aforementioned. If a participant's behavior interferes with the program, I will be contacted. Further disciplinary problems may result in expulsion from the program.

Permission for Medical Treatment *

In case of any accidents or injury, I authorize a staff member of 916 Ink to call the 911 emergency number. I give my consent to any treatment necessary by an attending physician for the physical well being of the child mentioned above. I further understand that the responding medical emergency team will provide emergency treatment as they deem necessary for the safety and protection of my child at my expense

Photography Release *

(We do not reveal last names in our publicity and it is rare that we release first names).

I do give permission to use the participant's photo for publicity purposes.

I do not give permission to use the participant's photo for publicity purposes.

Publishing Release *

I do give permission to publish the participant's Original Work in a publication and/or production of individual or various projects put forth by 916 Ink in the future. The work will be printed royalty-free, but the rights to the work shall remain the sole property of the youth author.

I do not give permission