September Pod Pop Up

September Pod Pop-Up

Join us as we tour the campus of Seattle Maritime Acamadey and take a leisurely ride around Lake Union. You don't want to miss this! Open to BIPOC (Black, Indigenous, People of Color) Age 12 and UP!
Date: September 28th, 2024

Time: 11:30am - 2:30pm

Location: 4455 Shilshole Ave NW, Seattle, WA 98107
- Participant Info
- First/Chosen Name *
  How should we address you?
- Pronouns *
  (Ex: she/her, he/him, they/them, etc)
- Date of Birth *
  
  MonthDayYear
  What's your birthday?
- Age*
- Participant Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Participant Email*
  example@example.com
- Zipcode*
  Please enter the zipcode of your home address
- Parent / Guardian Info
  
  Not required for participants aged 18+
- First Name *
  How should we address you?
- Pronouns *
  (Ex: she/her, he/him, they/them, etc)
- Parent/Guardian Primary Language(s)*
- Parent/Guardian Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Parent/Guardian Email*
  example@example.com
- Demographic Information
  
  Demographic questions are gathered for grant reporting purposes but all responses to your questionnaire will be kept confidential. Please answer to the degree of your personal comfortability and select "Prefer not to answer" for any questions you'd like to skip.
- BlackAfricanAmerican Indigenous or NativeAsianPacific IslanderLatine/LatinxHispanicMiddle EasternWhite or CaucasianMixed RacePrefer not to answerOther (please specify below!)
- Oops! Do you identify solely as White/Caucasian, and not as a Black, Indigenous, or Person of Color (BIPOC)? This program is a BIPOC-centered space, and may not be fit for you.
  
  If you believe there's been a mistake, please email info@letsseapotential.com for support.
- Participant identified as LGBTQAI+Participant is eligible for free/reduced school lunchPrefer not to answerNone of the above apply to the participant
- Accessibility & Transportation
- Does participant require accommodations to attend this program?
- Transportation Support
  
  Sea Potential is committed to providing transportation support to eligible individuals to attend youth and community programs. If you need transportation support, please learn more and fill out the survey linked HERE!
- Yes, I will fill out the survey to request transporation supportNo, I decline transportation support and will self-transport to the program
- I am fully aware that being a program participant with Sea Potential involves certain risks of physical injury or death. I further recognize the inherent dangers of water-related activities. I am informed of these risks and I assume all risk of injury to myself or my child. I agree to release and hold harmless Sea Potential, their respective employees, officers and agents, and any leaders of Sea Potential from any and all responsibility and liability of any nature that may arise during the program, including but not limited to any claims for property damage, personal injury, and/or communicative and infectious disease. This release includes any liability which may arise if the participant leaves the grounds of the program without authorization, or otherwise goes against the basic program guidelines. Without limiting the foregoing, I specifically waive all claims against Sea Potential, its employees and/or volunteers, and/or affiliated third parties, for any and all direct, incidental, and consequential damages relating in any way to Sea Potential, its programs or events.*
  
  I agree to these terms
- Media Release (optional): I hereby give permission to Sea Potential staff, and/or any person acting on their behalf to photograph and video my youth(s). This includes the consent to modify, edit, and reuse a photo or video. I understand that photos and videos may be used for the promotion and marketing of Sea Potential and any programs, activities, or events of Sea Potential. I expressly release Sea Potential and their respective agents, employees, licensees, and assigns from any and all claims which I have or may have for invasion of privacy, defamation, or any other cause of action arising out of the use of these photographs and video.*
  
  I agree to these termsI do NOT agree to these terms
- Participant Signature *
  
  Powered by Jotform SignClear
- Parent/Guardian Signature*
  
  Powered by Jotform SignClear
- Today's Date*
  
  MonthDayYear
  Date
- Oops! Do you identify solely as White/Caucasian, and not as a Black, Indigenous, or Person of Color (BIPOC)? This program is a BIPOC-centered space, and may not be fit for you.
  
  If you believe there's been a mistake, please email info@letsseapotential.com for support.
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September Pod Pop-Up

Participant Info

Parent / Guardian Info

Demographic Information

Accessibility & Transportation

Transportation Support