KIDS CREATE WORKSHOPS 2019

GNAT-TV KIDS CREATE WORKSHOP 2019 Registration
Student Info:
Student First Name:*
Student Last Name:*
Address:*
City:*
State:*
Zip:*
Birth Date:*

MonthDayYear
Current Grade Level*
Parent or Legal Guardian Info:
1) Parent/Legal Guardian Name (First, Last) :*
Relation to Student:*
Work Phone:*

Area CodePhone Number
Cell Phone:*

Area CodePhone Number
2) Parent /Legal Guardian:*
Relation:*
Work Phone:*

Area CodePhone Number
Cell Phone:*

Area CodePhone Number
Email:
- Please enter your email address correctly on this form to receive communications.
Parent/Guardian email:*
Repeat Parent/Guardian email:*
Student email:
Health Information:
1) Emergency Contact Name (First, Last):*
Emergency Number:*

Area CodePhone Number
2) Emergency Contact:*
Emergency Number:*

Area CodePhone Number
Please list any activities the student should be restricted from:
Please list any physical, mental, or other conditions that would require special attention or medication while at workshop:
Please list any known allergies (e.g. bees, peanuts, dairy, eggs). If none, type none:*
Student Other Information:
What School Do You Attend?
What are your favorite hobbies and subjects in school
Fine Arts/Graphic Design/Video Interest

Not InterestedWritingPerforming ArtsFilm MakingMusicGraphic Art/Photo/Painting/DrawingCookingStorytellingCostume and Set DesignDirecting/ProducingCamera Operator/Lighting/AudioReadingAnimationOther
How did you hear about GNAT-TV Kids Create Workshops?
I agree that photos/video of my child can be taken and used for television broadcast, promotional purposes, including web and printed media:*

Yes - You Must Fill Out a Talent Release FormNo
Payment Information
Method of payment:*

Check - Please mail payment to PO BOX 2168, Manchester Center, VT 05255Cash - Come see us!PayPal/Credit
Workshop Information - Professional Video Production and How to Make Your Own TV Show - Ages 8-13

Kids Create Workshop - November 6, 13, 20 December 4, 11 - 3:30-5:30pm
All workshops are from 3:30pm-5:30pm

GNAT supplies healthy snacks
Your payment will be processed online!

My Products

KIDS CREATE WORKSHOP - Nov. 6,13,20, Dec. 4,11$80.00

Total $0.00

Payment Method
Credit	Express
Credit	What is PayPal?

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Signature
Electronic signature, please initials:*
First Name, Last Name:*
I acknowledge that my initials typed here on this form are as legally binding as my printed signature, and, further, that I am the parent and/or legal guardian of the "listed student" and over the age of 18. I also attest to the accuracy of all information entered on this form and authorize qualified personnel to apply general medical teatment to the "listed student." In addition, I agree that the "listed student" will only be released from GNAT-TV Studio into the authority of the guardian listed on this form. I, further, certify that the "listed student" has my permission to attend this workshop series and participate in all workshop activites.
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GNAT-TV KIDS CREATE WORKSHOP 2019 Registration

Student Info:

Parent or Legal Guardian Info:

Email:

Health Information:

Student Other Information:

Payment Information

All workshops are from 3:30pm-5:30pm

Your payment will be processed online!

Signature