Uptown Stories Registration Form

Prefilled Section

This section is prefilled and hidden from the person filling out the form.
Workshop Name
Workshop Tuition
Workshop ID
Session
Max Students
Seats Taken
Workshop Type

CorePartnerCommunity
Subsidized Core Tuition
This is the coreSubsidized Tuition from Airtable
Community Partner
Seats Available
Waiting List Collector
Language Collector
Workshop Description
Descripción del Taller
Workshop Name: {workshopName}
Session: {Session}
Workshop Description

{workshopDescriptionEnglish}
Descripción del Taller

{workshopDescriptionSpanish}

I am registering*

A new studentA returning student
Wecome back! We are so happy to see you again.

Welcome to Uptown Stories! We are so glad you're here.
Child's First Name*
Child's Last Name*
Please address my child by*

her/his/their first nameher/his/their preferred name
Child's Name Collector

Workshop Description
{workshopDescriptionEnglish}

Descripción del Taller
{workshopDescriptionSpanish}

Learning Style

All children learn differently. Sharing your child's learning style is immensely helpful for their teachers.
Select the option or options that best describe {nameCollector}'s learning style.*

Reading/WritingAuditory - learns by listeningPhysical/Kinesthetic - learns by doingVisual - learns by watchingSocial/Group
Tell us more about how {nameCollector} learns best.
Is {nameCollector} neurodiverse?*

YesNo
Please tell us more about {herHisTheir} neurodiversity.
Does {nameCollector} have a learning disability or a learning difference we should know about?*

YesNo
Please tell us more about {herHisTheir} learning disability, or learning difference.

Emergency Contacts

We require 2 adult contacts for each student. The First Emergency Contact has been prefilled for you.
First Name*
Last Name*
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Relationship to {nameCollector}*

ParentLegal GuardianOther
First Name*
Last Name*
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Relationship to {nameCollector}*

ParentLegal GuardianOther

Terms & Conditions

Please review and sign our Child Release Form and our COVID-19 Agreement.

Child Release Form
I, {guardianFirst} {guardianLast}, on behalf of myself and my child, {childFirst} {childLast}, hereby grant permission to Uptown Stories Inc. (“Uptown Stories”) and its funders and partners without payment or any other consideration the rights of my child’s

(i) image, likeness and sound of their voice as recorded on audio or video tape,

(ii) writings produced in conjunction with Uptown Stories’ lessons.

I understand that my child’s images or writings may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein same appears. Photographic, audio or video recordings and child’s writings may be used for fundraising and other promotional and marketing purposes or in diverse educational settings, both in hardcopy and for electronic distribution.

There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. This form shall be signed by electronic signature, and the electronic signature below and their related fields are treated by Uptown Stories Inc. and its funders and partners the same as would be a physical, handwritten signature on a paper form.

By my signature below, I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for the purposes stated above.

COVID-19 Agreement
Should {childFirst} {childLast} or anyone in {herHisTheir} immediate household be diagnosed with Coronavirus/COVID-19 or experience symptoms associated with Coronavirus/COVID-19, I will immediately notify Uptown Stories at info@UptownStories.org and/or 929-277-8679. I will also refrain from sending {childFirst} {childLast} to in-person workshops until Uptown Stories gives permission for {herHisTheir} return.

Electronic Signature
Electronic Signature*
This signature signals acceptance of the Terms & Conditions above.

Tuition & Payment

Because you are on the waiting list for {workshopName}, there is nothing due today for tuition.
Tuition Option*
Tuition Amount
If you select Pay-What-You-Can, please indicate how much you are going to pay for your tuition.

Would you like to make an additional donation to Uptown Stories today?

YesNo
Donation Amount
Total Amount to Payment
Payment Method*

Credit Card (Recommended)Check or Money Order

Total Due

USDDescription

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Submission Date and Time*

MonthDayYear
Date
Should be Empty:

Prefilled Section

Student Information

Learning Style

Health Information

Parent/Guardian Information

Emergency Contacts

Terms & Conditions

Tuition & Payment