Registration Form

Register online below, or click to download the pdf packet here!

Name of Writer *
Name of Writer
Gender *
Primary Language Spoken at Home *
Choose One
Family Information
Guardian One
Guardian One
Please indicate:
Guardian One's Home Phone
Guardian One's Home Phone
Guardian One's Work Phone
Guardian One's Work Phone
Guardian One's Cell Phone
Guardian One's Cell Phone
Guardian Two
Guardian Two
Please indicate:
Guardian Two's Home Phone
Guardian Two's Home Phone
Guardian Two's Work Phone
Guardian Two's Work Phone
Guardian Two's Cell Phone
Guardian Two's Cell Phone
Please indicate:
Home Address
Home Address
Emergency Contact Information
Name of 2 alternative friends or relatives who can be contacted in case parent/guardian cannot be reached:
Name 1
Name 1
First alternate contact
Phone
Phone
Second alternate contact
Phone
Phone
Authorized Person(s) to Pick Up Students
My child is authorized to walk home at the end of the day on the following days:
Approved for Pick Up
Name 1
Name 1
Phone
Phone
Name 2
Name 2
Phone
Phone
People NOT Approved for Pick Up
Name 1
Name 1
Phone
Phone
Name 2
Name 2
Phone
Phone
Liability
Release of Liability *
Medical Treatment
Permission for Medical Treatment
Guardian Signature *
Please list:
Photography Release
Permission to use child’s photo
Please indicate whether 916 Ink has permission to use your child’s photo for publicity purposes. (We do not reveal last names in our publicity.)
Publishing Release
Permission to publish child’s work
Please indicate whether 916 Ink has 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. (See also Author Release and Contract.)