Summer Ink Registration

Register for Teen Editors 2022!
Thank you for registering for Lake Erie Ink's 2022 Teen Editor Project! You should receive a confirmation email upon completion of this form. If you have any questions, please call 216-320-4757. Thank you!
Parent/Guardian Email Address*
example@example.com
Student Name*

First NameLast Name
Select the program you are registering for*

Teen Editors 2022-23

Participant Information
Student Birthdate*

MonthDayYear
Date
Student Pronouns (she/her, he/him, they/them, etc.)
Student School*
Student Grade for the 2022-2023 School Year*
Student Home Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Demographic Information

The following demographic questions help Lake Erie Ink report and apply to funders upon request. All information will remain confidential.
Student's ethnicity:*

AsianBiracialBlack or African AmericanHispanic or LatinoNative American or AlaskanPacific Islander or HawaiianWhite or CaucasianPrefer not to answerOther
Student's first language, if not English:

Learning & Medical Concerns
Please describe any special learning concerns you might have for your child:
Please describe any medical or health concerns (i.e. allergies, asthma, diabetes, etc.):
In the event that the individual(s) listed above cannot be reached in an emergency, I hereby give my consent for emergency medical treatment by a licensed professional and the transfer of my child to a local hospital.*

YesNo

Permissions
Student email which will be used during the virtual program.*
example@example.com
Please check the box below confirming that you understand that Lake Erie Ink teachers are collecting emails to be able to communicate with your child about the workshops using online means (email or Zoom platform). If you have any questions or concerns please email: cbailey@lakeerieink.org*

YesNo
I give permission to Lake Erie Ink to photograph/videotape my child while participating in program activities. These photos or videos may be used to promote Lake Erie Ink programs.*

YesNo
I give permission for Lake Erie Ink: a writing space for youth to publish my student’s work in any Lake Erie Ink publication, including our student anthologies, website, social media, blog, vlog, or podcast, using my first name, last initial, and age/grade.*

YesNo
Freedom of Expression Policy: Lake Erie Ink believes in freedom of speech and respects the right of all participants to express themselves honestly and creatively. However, we reserve the right to contact parents/guardians/school authorities if we feel the content of a participants work suggests possible harm to self or others. I have read and consent to the Lake Erie Ink Freedom of Expression policy:*

YesNo
Parent/Guardian Signature*

Clear
Student Signature:*

Clear

You're Almost There!
How did you hear about this program?*
Where exactly did you hear about this program? Please be as specific as possible. For example: "My teacher, Ms. Geiger told me," or "I saw it on a flyer at Starbucks."
Newsletter

Yes, subscribe me to Lake Erie Ink's newsletter.
Should be Empty:

Register for Teen Editors 2022!