Artgevity LLC's Community Outreach Registration Form
Creativity Encore United Youth & Family Services
Sign Up Date
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Month
-
Day
Year
Date
Name
First Name
Last Name
Age
Date Of Birth
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Month
-
Day
Year
Date
Gender
Telephone Number
Please enter a valid phone number.
Email
example@example.com
Residential Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Ethnicity
American Indian or Alaska Native
White
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Hispanic or Latino
PAST/ PRESENT STATUS 1. Spoken language(s)? 2. Life challenges? 3. Medical history/ Allergies? 4. Treatment history? 5. Current medication list? 6. Emergency contact info? 7. Suicidal ideation history?
Grade Level
PreK-2
6-9
3-5
10-12
Do you have experience in performing arts?
Yes
No
What's your hobby /art form/ instrument of choice?
Education / Performance Program History
Rows
School/ Program Name
Level
Duration
Location
1
2
3
4
5
Upload Student Photo ID, Insurance Info/ Card, Report Card, and Parental/ Guardian Photo ID, Insurance Card & Other Verification Documents
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Areas of expertise?
Why are you interested in participating in this program?
What are some of your best qualities? What are some things about yourself and in your life in which you believe you would like to see a greater improvement?
What are your needs, wants, goals and ambitions?
Attach any performing arts/ mentorship related programs/ treatment centers/ residential facilities that you've attended {e.g. camps; group homes; homeless shelters, etc...}
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Student/ Participant Signature
Parent/ Guardian Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
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