Class Registration Form for Freedom Summer 🌞🎨ðŸŽ
Please fill out the registration form below to sign up for the Freedom Summer Program hosted by Los Angeles County Supervisor Holly J. Mitchell in partnership with Heart & Soul Center/Image Village. This free 8+ week program offers hands-on creative workshops in multimedia arts, photography, and performing arts for youth in the community. Classes will take place Wednesdays from 2 - 4 PM at George Washington Carver Park. Please complete all required fields to help us better support participants throughout the program. Space may be limited.
Participant Information
Participant Full Name
*
First Name
Last Name
Participant Date of Birth
 -
Month
 -
Day
Year
Date
Participant Age
*
Grade level
School
Accessibility / Support Needs
Does the participant have any accessibility, medical, or support needs we should be aware of? If so, please explain below. If none, please write n/a
*
Parent/Guardian Information
Full Name
*
First Name
Last Name
Relationship to Participant
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Program Interest & Attendance
Which station are you most interested in?
*
Multimedia Arts (Creative crafts)
Photography (Fundamentals, lighting, composition)
Performing Arts (Acting, spoken word, movement)
Interested in all activities
Classes are every Wednesday from 11 am - 1 pm. Will participant attend most sessions?
*
Yes
No
Unsure
Media Release
I understand photos and videos may be taken during program activities for educational, promotional, and community outreach purposes.
*
I consent
I do not consent
Final Agreement
I confirm the information provided is accurate and understand participation in the program is voluntary.
Parent Name
*
First Name
Last Name
Date
*
 -
Month
 -
Day
Year
Date
Register
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