SRBCC PODCAST WORKSHOP REGISTRATION FORM
June 15th, 2024 - 11:00 am - 3:00 pm. 4048 West Armitage Ave, Chicago. IL
Participant's Name
*
First Name
Last Name
E-mail
*
example@example.com
Age Group
*
14 to 17 years old
18 to 21 years old
21 to 25 years old
25 to 30 years old
Over 30 years old
Phone Number
*
If under 18, and no personal phone, please input your guardian's phone number.
Zip code
*
What pronouns do you use?
*
She/her/her
He/him/his
They/them/their
Ze/hir/hir
Are you currently in School?
*
Please Select
Yes, I'm currently a High School Student
No, I am not currently in School
If you are currently attending school, please tell us where
Back
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Parents Contact Information
This section is MANDATORY for all applicants under 18 years old
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Emergency Contact Person #1
First Name
Last Name
Emergency Contact Person #1 Phone Number
Please enter a valid phone number.
Emergency Contact Person #2
First Name
Last Name
Emergency Contact Person #2 Phone Number
Please enter a valid phone number.
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