YEP’s Media & Storytelling Registration Form

MEDIA & STORYTELLING REGISTRATION
Please complete one form per participant. Submission does not confirm placement. YEP will contact the parent/guardian regarding acceptance, schedule details, and next steps.
PARTICIPANT INFORMATION
Participant Full Name *

First NameLast Name
Preferred Name

First NameLast Name
Date of Birth *

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age *
School
Current Grade
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant Email (if applicable)
example@example.com
PARENT / GUARDIAN INFORMATION
Parent / Guardian Full Name *

First NameLast Name
Relationship *
Primary Phone *
Format: (000) 000-0000.
Email *
example@example.com
Alternate Phone
Format: (000) 000-0000.
Preferred Contact Method
EMERGENCY CONTACT
Emergency Contact Name *

First NameLast Name
Relationship
Emergency Phone *
Format: (000) 000-0000.
Alternate Phone
Format: (000) 000-0000.

MEDIA & STORYTELLING REGISTRATION