Ankorz Up Youth Kickback

Saturday, November 14, 2026

Event Time: 11:00 AM-1:30 PM

Location: BPT Creates
1001 Main St Unit 14, Bridgeport, CT 06604

Note: BPT Creates is located between the Arcade Mall and Reads Artspace. You can get there by going through the Arcade Mall from Main Street or from Broad Street.

Attire: Casual Neat

Note: This event is for youth ages 14-18.

Important: Please ensure ALL fields are completed before submitting your registration. If a question or section (such as ‘Other’) does not apply to you, please enter ‘N/A

Student Name

First NameLast Name

Birth Date

MonthDayYear

Grade Level

School

example@example.com

Email

example@example.com

Cell Phone

Please enter a valid phone number.Format: (000) 000-0000.

Home Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Will you be attending the Youth Kickback on Saturday, November 14, at 11:00 AM?

During the Youth Kickback, we'll have opportunities for you to share what you'd like to learn through our upcoming future programs. What topics would you be most interested in learning about? Select your top 3 topics or share an idea of your own!

Other

If you selected other for your answer, please let us know what you would like to learn.

Lunch will be provided. Do you have any dietary restrictions, food allergies, chronic illnesses, or medical conditions we should be aware of?(Please specify).

Transportation: How will you be traveling to the event?

Behavior/ Misconduct Policy (For all attendees)

The Youth Kickback is developed to create a safe and fun learning environment and will not accept misconduct or disruptive behavior such as being rude, disruptive, loud, mishbehaving, disrespectful, uncoorperative.

By attending the event, I understand and will adhere to the policies, failure to uphold this policy will result to being asked to leave the event. Your parent/guardian or emergency contact will be called to pick you and you will no longer be able to participate in any activity during the event

Do you understand this policy

Parent/Guardian Information

(Must be completed for ALL attendees)

Parent/Guardian Name

First NameLast Name

Cell Number

Format: (000) 000-0000.

Home Number

Format: (000) 000-0000.

E-mail

example@example.com

Informed Consent and Acknowledgement

I hereby give approval for my child’s participation in any and all activities prepared by {Ankorz Up} during the Youth Kickback. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless {Ankorz Up} and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from the event. In case of injury to my child, I hereby waive all claims against {Ankorz Up},volunteers, partners, affiliates, all participants, sponsoring agencies, venue, and more at the event.

Informed Consent and Acknowledgment

Photo & Video Release

By checking off the the preceding box, I will either consent or do not consent to Ankorz Up use of quotes, photographs,video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration as it relates to this event.

Even though I have checked this box, I understand that it is as, my parent, or my child’s responsibility to specifically notify either the person in charge of the event, the photographer or any other adult who is involved at the event of my refusal to not allow my child’s quotes, photographs, movies or video tapes that could/are made during this event to be used by Ankorz Up.

Photo & Video Release

How did you hear about this event?

If Other, please specify

Date

Note to All Event Attendees: As the event approaches, you’ll receive email reminders details.

Please review your information and ensure your contact details are correct before clicking submit.

School