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.
Participant is under 18
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?
Cost Level Selection
Select Billing Frequency
How much are you able to contribute per week for this program?
Preferred Payment Method
How would you prefer to be contacted?
How would you prefer to be contacted?
What time of day would you prefer to be called?
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.
By checking this box you indicate the fact that you understand that if you receive a scholarship I will be expected to attend a minimum of 3 meetings per week for the entire 7 week duration of the program.
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.

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By checking the box below the participant consents to being photographed during the program. These photos may be used for social media posts or advertisements in the future.
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