Herstory Writers Workshop

1

To be completed by parent/guardian. As parent/guardian of:* This field is required.I give my permission for him/her to participate in the ERASE Racism and Herstory Writers Workshop occurring on Monday, January 15, 2018, from 9:30 a.m. to 3:30 p.m. at ERASE Racism's office: 6800 Jericho Turnpike Suite 109W.

Name of Student

Name of School/ Organization

2

I agree that I will supply or approve transportation to and from the meeting. ERASE Racism will not provide transportation.* This field is required.

Yes

No

3

I agree that ERASE Racism may use photographs, videotapes, audio recordings, or other transmissions of my child for public relations, educational or other purposes, including but not limited to use on the ERASE Racism Website, Facebook, and Twitter pages or in newsletters and media releases. I agree that these materials shall become the property of ERASE Racism and release and discharge ERASE Racism and its representatives from any and all claims that may arise from the use of such property.* This field is required.

Yes

No

4

Medical information including allergies:

5

5 Dietary Needs (We will be serving lunch)

6

Parent/Guardian Contact Information* This field is required.

Name

Please enter your email

Please enter a phone number

Please enter an alternate number

Home Address

7

Signature of Parent or Guardian* This field is required.