NVIM Creation Station Program-In person

1
Parent(s) Name:
First Name
Last Name
2
Parent Email* This field is required.
example@example.com
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Parent Telephone Number* This field is required.
Area Code
Phone Number
5
Child's Name* This field is required.
First Name
Last Name
6
Child's Age (13-18)* This field is required.
11
12
13
14
15
16
17
18
7
Child's Grade (High School Only)* This field is required.
9th Grade
10th Grade
11th Grade
12th Grade
8
Please list your child's food allergies if applicable.
Huge
Large
Normal
Small
Ok
Ok
9
What are your student's interests?* This field is required.Please note that students are required to participate in all tracks.
Coding
Video Production
Audio Engineering
Intro to Multimedia (Effective Communication)
STEM
Health and Wellness
10
Signature* This field is required.I give permission for my child listed above to participate and attend all Creation Station Learning Modules. Both my child and I understand that attendance is mandatory and participation in all the 4 week modules from Monday to Friday from 4:00pm to 6:00 pm, February 6, 2023 to March 3, 2023 is necessary to complete the program. No class February 20, 2023 (President's Day). In case of emergency, I will notify the Program Director in advance of any emergencies that may arise with the parent or student prior to start time of class that may hinder the student participation. Both my child and I agree to all COVID-19 guidelines according to the CDC and wearing a mask is optional while participating in programs at New Vision or while in the building. Both my child and I agree to those expectations of the program.
ClearPlease sign parent or guardian name here
11
Signature* This field is required.Certification and Consent: I hereby certify that the information entered on this form is complete to the best of my knowledge. I consent to have this information entered and saved into the New Vision International Ministries (NVIM) Creation Station Program database for reporting purposes. I also understand that my child must return the program issued Chromebook and all equipment to the program after each use in class. Both my child and I agree to those expectations of the program.
ClearPlease sign parent or guardian name here
12
Signature* This field is required.I hereby give my consent to allow my child to fully participate in the Creation Station Program online in the event of inclement weather. I agree by creating a Zoom account on your child's behalf which the Maker Mentors will communicate to you and your child, teach curriculum and equip your child with a transferable skill set in the areas of Audio Engineering, Video Production, Intro To Multimedia (Effective Communication), Health and Wellness and STEM. This account must remain active from February 6, 2023 to March 3, 2023.
ClearPlease sign parent or guardian name here
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