Summer Program and Block Print Registration Form

Summer Program and Block Print Registration Form

Please fill out your details to register for the summer program.
Participant's Full Name*

First NameLast Name
Participant's Pronouns*
Participant's Email*
example@example.com
Participant's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Date of Birth*

MonthDayYear
Date
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian Full Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
Parent/Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact's Relationship to Participant*
Does the participant have any allergies, medical conditions, or special needs?
Which summer program session are you interested in?*
I am able to pay full pricing (payment plans available)I would like to speak with someone about sliding scale pricing.I would like to apply for full scholarship coverage
Weekly Payment - $280 ($70 per day)Half term - $840 ($60 per day)Full Term 28 - $1,400 ($50 per day)
How much are you able to contribute per week for this program?*
PaypalVenmoCashAppCashCheck
Participant's PhoneParticipant's EmailGuardian's PhoneGuardian's Email
PhoneEmail
MorningAfternoonEveningNight
Please write 400-800 words detailing why you are interested in joining Writer's Block Ink's Summer Program as well as why receiving this scholarship is necessary for your participation.*
I understand.
Please upload an example of your strongest piece of creative work. This can be any form of creative art that you feel most represents your talents.*

Cancelof
I consentI do not consent
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