Youth Media Center Registration - Parent/Guardian Form

Youth Media Center Registration - Parent/Guardian Form
Thank you for your interest in teen programming at the SLB Radio Youth Media Center! This registration form must be filled out and signed by a parent/guardian. All students must have a current registration form on file in order to participate in programming.

Once registered, students are eligible to:
- Attend after school and weekend Open Studio sessions at the Youth Media Center
- Participate in workshops, classes, and special events
- Access youth reporter opportunities
- Participate in live, youth-focused segments on The Saturday Light Brigade radio show.
Visit ymc.slbradio.org to learn more about upcoming opportunities for teens.

SLB Radio's Youth Media Center is co-located within the Children's Museum of Pittsburgh at 10 Children's Way, Pittsburgh, PA 15212. More information about SLB Radio can be found at slbradio.org.

Have a question? Reach out! Send an email to youthmediacenter@slbradio.org.
Student Information
Student Name*

First NameLast Name
Student Email
Student Phone
Student Date of Birth*

MonthDayYear
Gender
Student Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence*
What school to you attend?*
Grade Level as of Fall 2025*
Expected Year of High School Graduation
If your child has already graduated high school, please put the year in which they graduated.
Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Phone Number*
Parent/Guardian Email*
Additional camp information will be shared via email.
Parent/Guardian Mailing Address*

Same as student's mailing addressDifferent from student's mailing address
Parent/Guardian Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like to input information for a second parent/guardian?

YesNo
Parent/Guardian 2 Name

First NameLast Name
Parent/Guardian 2 Phone Number
Parent/Guardian 2 Email
example@example.com
Parent/Guardian 2 Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alternate Emergency Contact & Student Health Information
We must have information for an Alternate Emergency Contact on file. This person must be an 18+ individual that is not the student's parent/guardian. The Alternate Emergency Contact will only be contacted if the parent(s)/guardian(s) cannot be reached.*

Alternate Emergency Contact First NameAlternate Emergency Contact Last Name
Alternate Emergency Contact Phone*
Relationship to Student*
Does your child have any of the following health conditions?*

AsthmaDiabetesEpilepsyAllergies (Food/Drugs)NoneOther
Please list any allergies to food/drugs:
Are there any other health conditions we should be aware of?
Does your child have any dietary restrictions (i.e. vegetarian, gluten-free, etc.)?
Is there anything else you'd like us to know?
Policies & Release Form
Youth Media Center Policies

For up-to-date program information, including hours of operation, visit ymc.slbradio.org. After school teen programming at the Youth Media Center is designed for students in grades 6 - 12.

All students are expected to leave the Youth Media Center and Children’s Museum campus promptly at the end of programming hours. Adult supervision is not provided outside of programming hours, and SLB Radio staff are not responsible for students after they leave the Youth Media Center.

Students are responsible for arranging or providing their own transportation to and from the Youth Media Center. SLB Radio does not provide transportation for students. To support students who may need transportation assistance, PRT bus passes are available upon request.

Students are expected to understand and respect the SLB Community Standards. Students who choose not to respect these standards will be asked to leave the Youth Media Center and may not be permitted to attend programming in the future.
By checking this box, I acknowledge that I have read and agree to the above policies.*

I understand.
SLB Radio Release Form

Information Release: I consent to having my child’s basic information (name, school, grade level, date of birth, and days of attendance) shared with the Allegheny County Department of Human Services.

Medical Release: In the event of an emergency situation, I authorize SLB Radio to contact emergency personnel to transport my child to the emergency room. I agree that SLB Radio is not responsible for any costs or expenses incurred.

Media Release: SLB Radio Productions offers a wide range of media-making programs for youth, giving students the opportunity to learn about digital recording, editing, writing, and related skills as they work with peers and adult mentors in a professional environment at SLB Radio’s Youth Media Center.

Work created during these programs may include audio recordings as well as photographs, short videos, news articles, social media posts, and other related media which SLB Radio Productions may share online and/or in print for the purpose of documentation, promotion, and–most importantly–celebrating the voices of the youth we serve.

I give permission for the work created by my child to be shared/distributed as described above.
By signing below, I agree to the release statements listed above.*

Clear
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Youth Media Center Registration - Parent/Guardian Form

Student Information

Parent/Guardian Information

Alternate Emergency Contact & Student Health Information

Policies & Release Form