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Student Ambassador Program Application
Please complete this form in full. It serves as your application and contact form, outlines project expectations and requirements, and includes a Parental Consent & Liability Waiver for students under 18.
Name
First Name
Last Name
Nominating Teacher:
Preferred Email:
Methods of Communication You Use:
Remind
Google Classroom/ Google Chat
Slack
Discord
GroupMe
Email
Other
Program Requirements
Participation in this program requires that you attend the Zoom orientation (date and time TBD), participate in three in-person workshops at the Patchogue Arts Council • MoCA L.I, and attend the final culminating event (performance or exhibition). You must provide your own transportation (self or parent/guardian) to and from all in-person events.
Acknowledgment: I have read and understand the the participation requirements for the PEACE Student Ambassador Program, and agree to attend all scheduled sessions and events.
Parental Consent & Liability Waiver
I give permission for my child to participate in the PEACE Student Ambassador Program organized by the Patchogue Arts Council. I consent to the use of my child’s name, photo, and video for program and promotional purposes. I understand my child will take part in both virtual and in-person activities and that I am responsible for their transportation. I release the Patchogue Arts Council, its staff, teaching artists, and affiliates from any liability for injuries, loss, or damages that may occur during program participation.
Parent/ Guardian Name:
First Name
Last Name
Parent/ Guardian Phone:
Please enter a valid phone number.
Parent/ Guardian Signature:
Submit
Should be Empty: