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StoryArk Middle School Summer Camp 2024
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28
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1
Student Name
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First Name
Last Name
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2
Your mailing address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
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Belgium
Belize
Benin
Bermuda
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Bolivia
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Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
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Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
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India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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3
Student date of birth
*
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-
Date
Month
Day
Year
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4
Student Gender
*
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Male
Female
Non-Binary
Prefer not to say
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5
Student Email
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example@example.com
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6
Student phone number
(If applicable)
Please enter a valid phone number.
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7
Are you able to receive texts?
*
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YES
NO
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8
Current Grade
*
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Please Select
5th
6th
7th
8th
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Please Select
5th
6th
7th
8th
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9
Your School District
*
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TC Districts
Stillwater Area Public Schools
Hastings
Forest Lake
Inver Grove Heights
Roseville
White Bear Lake
South St. Paul
Other
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10
If your district is not listed, please list it here.
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11
Your School
*
This field is required.
Please Select
Forest Lake Area
Hastings
Inver Grove Heights
Roseville Area
Simley
Stillwater Area
White Bear Lake Area
Other
Please Select
Please Select
Forest Lake Area
Hastings
Inver Grove Heights
Roseville Area
Simley
Stillwater Area
White Bear Lake Area
Other
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12
If your school is not listed, please list it here.
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13
Will you require transportation to and from camp?
*
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YES
NO
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14
Pick up and Drop off Address
Please provide the address(es) you will need to be picked up from and dropped off at
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15
What medium are you most interested in exploring?
We'll be exploring multiple mediums, which medium are you most interested in exploring? Podcast, Visual Arts, Music, Creative Writing, Playwriting, other?
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16
Race/Ethnicity/Communities
*
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This information and language is required by our grantors. Your willingness to indicate helps us receive resources to serve students. Please note that this information will remain PRIVATE and names will NEVER be attached to data.
Please Select
Asian/Asian American
African/Black/African American
Afro-Latinx
Hispanic/Latinx/Chicanx
Middle Eastern/North African
Mixed - more than 1 race
Native America/American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
White/Non-Hispanic
Prefer not to say
Please Select
Please Select
Asian/Asian American
African/Black/African American
Afro-Latinx
Hispanic/Latinx/Chicanx
Middle Eastern/North African
Mixed - more than 1 race
Native America/American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
White/Non-Hispanic
Prefer not to say
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17
Disability/Different Ability and Accommodations
If applicable. StoryArk is committed to providing access to all of our programing. If you have a disability and may require accommodations to participate, please indicate that here. If you have questions, please email Jenna at jenna@storyark.org
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18
Dietary Needs, Restrictions, or Allergies
Put "None" if not applicable
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19
Why do you want to participate?
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20
What do you hope to learn? What are you looking forward to?
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21
Anything we should know?
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22
How did you hear about StoryArk's Summer Camp?
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23
Parent/Guardian Name
*
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First Name
Last Name
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24
Parent/Guardian Email
*
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example@example.com
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25
Parent/Guardian Phone Number
*
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Please enter a valid phone number.
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26
Parent/Guardian Signature
I authorize my student, named above to participate in StoryArk's programming. I release StoryArk of all liability of injury, death, or other damages to me, my child, or family that may result from his/her participation in the program, including but not limited to transportation, and hold harmless any StoryArk program staff, volunteer, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined. I give permission to StoryArk staff, volunteers or other representatives to seek medical attention for my child if needed during the course of their participation in the program. I give permission for my child to utilize various technologies and access to the internet for educational purposes.
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27
Marketing and Promotions
*
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I give permission for photos or video recordings and partial or complete quotes of my child to be reproduced for promotional and educational purposes and/or related events. (Please note, your child's personal information, including name, school, etc will be used)
I DO give permission for photos or video recordings and partial or complete quotes of my childto be reproduced for promotional and educational purposes and/or related events.
I DO NOT give permission for photos or video recordings and partial or complete quotes of my child to be reproduced for promotional and educational purposes and/or related events.
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28
Intellectual Property Rights
*
This field is required.
In consideration for the mentoring and educational opportunities being given to me by StoryArk and in recognition of StoryArk's collaborative creative process, I give StoryArk permission to use my image and my voice in its publications, podcasts, videos, social media and in all other formats without additional compensation. I hereby assign and transfer to StoryArk all right, title and interest that I may have in materials created while working for or with StoryArk, including but not limited to: written materials, videos, audio recordings, digital recordings, images and anything else produced for StoryArk or its projects, podcasts and videos. StoryArk hereby grants me a license to use the images, audio and materials on my personal reels, portfolios and resumes. I may also reproduce and distribute the materials to my instructors, teachers, and professors to receive academic credit for the work performed. This license does not give me the right to revise, add content or otherwise create derivative works from the items listed above without express permission of StoryArk.
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StoryArk High School Summer Camp 2024 Registration
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