Take ACTion Interest Form
Stand Up and Speak Out
Guardian Information
Guardian Name
First Name
Last Name
Guardian Email
example@example.com
Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Youth Information
Youth Name
First Name
Last Name
Youth Email
example@example.com
Youth Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Youth Grade Level
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
What role(s) would youth be interested in (select all that apply)
Concept creation
Script writing or editing
Acting
Production
Aiding in curriculum creation
Presenting
Promotion
Contact Confirmation
I/we would like to be contacted regarding (select all that apply)
Take ACTion planning meetings
Take ACTion practices and filming
Take ACTion community events
Take ACTion short film releases
Take ACTion youth presentation opportunities (to book a Take ACTion presentation please email ashleyw@wavi.org and kristin.kiner@k12.sd.us)
Ways to support Take ACTion projects
I/we would like to be contacted in the following ways (select all that apply)
Guardian Email
Guardian Phone (call)
Guardian Phone (text)
Youth Email
Youth Phone (call)
Youth Phone (text)
Signature
Guardian permission for youth listed above to be involved in Take ACTion, including discussions on difficult topics (There may be further signed permission required pending youth role)
Submit
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