Uptown Stories Registration Form

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 {sheHeThey} neurodiverse?*

YesNo
Please tell us more about {herHisTheir} neurodiversity.
Does {sheHeThey} 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 Contact 1 - First Name*
Emergency Contact 1
Emergency Contact 1 - Last Name*
Emergency Contact 1
Emergency Contact 1 - Phone Number*
Emergency Contact 1
Emergency Contact 1 - Email Address*
Emergency Contact 1
What is {emergencyFirst_1}'s relationship to {nameCollector}?*

ParentLegal GuardianOther
emcoFirstRelationshipCollector

Emergency Contact 2 - First Name*
Emergency Contact 2
Emergency Contact 2 - Last Name*
Emergency Contact 2
Emergency Contact 2 - Phone Number*
Emergency Contact 2
Emergency Contact 2 - Email Address*
Emergency Contact 2
What is {emergencyFirst_2}'s relationship to {nameCollector}?*

ParentLegal GuardianOther
emcoSecondRelationshipCollector

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.
Please type your full name as your Electronic Signature*
Your Electronic Signature indicates that you accept the Terms & Conditions above.

Tuition & Payment
Matrícula y pago

The cost of this workshop is ${prefillWorkshopTuition}.00. As with all of our workshops, we offer a Pay-What-You-Can option. We ask that every family contribute as much as you're able to afford at this time.

Tuition Option*
Please enter your Pay-What-You-Can tuition
Tuition Collector

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

YesNo
Donation Amount
If applicable, please type in your coupon code from the Fort Tryon Park Trust

Fort Tryon Park Discount
Payment Method*

Credit Card (Recommended)Check or Money Order

Total Amount to Payment
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Total Due

USDDescription

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

Submission Date and Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

Prefilled Section

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