Pixels with Purpose Photography and Videography Program Registration Form 📸🎥✨

Pixels with Purpose Photography and Videography Program Registration Form 📸🎥✨

Please complete this form to enroll in the 4-week Pixels with Purpose program from June 6 to July 4, 2026. Ensure all information is accurate; enrollment is limited to 25 participants.
Participant Information
First Name*
Last Name*
Date of Birth*

MonthDayYear
Date
Age
FemaleMaleNon-binaryPrefer to self-describePrefer not to say
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
School or Current Educational Status
Grade Level
Employment Status
How Did You Hear About the Program?*
City*
Emergency Contact
Emergency Contact Name*

First NameMiddle NameLast Name
Relationship to Participant*
Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Program Interest and Access Needs
PhotographyVideographyEditingStorytellingContent creationOther
Prior experience with photography or video
Preferred area of focus*
Smartphone onlyCamera onlyBothNeitherOther
Goals for joining the program
Support or accessibility needs
YesNoSometimesOther
Medical or allergy information relevant to participation
Additional comments
Required Acknowledgments and Consent
Yes
Yes
Yes
Yes
Yes
Yes
Minor or Adult Signature Section
Parent/Guardian Name

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

MonthDayYear
Date
Should be Empty:

Pixels with Purpose Photography and Videography Program Registration Form 📸🎥✨

Participant Information

Emergency Contact

Program Interest and Access Needs

Required Acknowledgments and Consent

Minor or Adult Signature Section