SUMMER 2025 Middle School: Youth Arts Program, CHICAT

Current grade OR highest level of education completed:*
School Name*
CPS/Student ID# (if applicable):
Does student qualify for Free or Reduced Priced Meals in School?*

YesNoNot Sure
Does the student receive an IEP in School?*

YesNoNot Sure
Does the participant have a disability? (Check one)*

YesNo
What special needs or considerations should CHICAT staff know about this student prior to enrollment?
PARENT/GUARDIAN INFORMATION*

First NameMiddle Initial (M.I.)Last NameSuffix(Jr., Sr., III)
Relationship*
Mobile Phone*
Email Address*
Emergency Contact Name*
Emergency Contact Phone Number*
Emergency Contact Relationship*

READ AND SIGN

(If student is under 18 please have Parent/Legal Guardian sign.)

My signature below indicates that I have read, understood, made correct, and completed statements on this application and any supplements to it. I understand that any omission or false statement made by me will result in disqualification, or discharge from program.
Student's Signature *

Clear
Date*

MonthDayYear
CONSENT AND RELEASE

I consent to interviews, photographs, and audio and video recordings of myself (collectively, “Personal Images” I grant the Chicago Center for Arts Technology (CHICAT) and the Department of Family and Support Services (DFSS) irrevocable right to use, reproduce (whether through digital copying, photography, audio, and video recordings, or any other means), release, publish, transmit, distribute, exhibit, and/or display in any and all forms of media (whether existing or future, and whether in whole or in part) and in any and all manners, including (1) any or all of my artwork that is created at or through CHICAT and DFSS, (2) any or all of the Personal Images, and (3) my name and likeness. The preceding consents are given for and limited to CHICAT and DFSS’s activities as a non-profit institution. Such activities may include, without limitation, news articles, telecasts, webcasts, press releases, education, fundraising, marketing, advertising, and research. Such activities may be performed by CHICAT or CHICAT’s employees, agents, affiliates, partners, assignees, licensees, or designees.

I waive all rights to inspect or approve any uses that may be created under the preceding paragraph, or the use to which any of the materials may be applied. I waive the right to compensation by, through, or under CHICAT for any uses that may be created under the preceding paragraph. I agree that Personal Images and all other originals thereof shall constitute CHICAT’s sole property, with the full right of disposition in any manner whatsoever.

I release, discharge, and agree to hold harmless CHICAT, its agents, affiliates, partners, assignees, licensees, and designees, and all persons acting under its/their authority from any and all claims whatsoever in connection with the use of the materials as described in the first paragraph above. I certify that I either (a) am 18-years old and legally competent to execute this Consent and Release or (b) am under 18-years old and have the consent of my parent or guardian to execute this Consent and Release. I understand that the terms herein are contractual and not a mere recital, that this instrument is legally binding, that I have voluntarily signed this document, and that CHICAT is relying on this Consent and Release to perform the activities described in the first paragraph above. I have read this Consent and Release and am fully familiar with its contents.
Student's Signature *

Clear
Date*

MonthDayYear
Parent/Legal Guardian's Signature *

Clear
Date*

MonthDayYear
Should be Empty:

Summer 2025 Middle School Application