Form

Student Name (1)

First NameLast Name

Student Name (2)

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

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

Email

example@example.com

Parent/Guardian Name

First NameLast Name

Phone Number

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

Email

example@example.com

Emergency Contact Name

First NameLast Name

Emergency Contact Number

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

Allergies

Please list any food allergies above.

What is your grade level?

What school do you attend?

What is your favorite subject?

T-Shirt Size

Heels & Ties Too Success Inc.

Re: Photo, Video & Media Authorization Release

As the parent of the child(ren) hereby grant permission to Heels & Ties Too Success Inc., its representatives, employees, volunteers, partners, and authorized media personnel to photograph, videotape, record, and/or capture my image, voice, likeness, or the image and likeness of my child during participation in programs, activities, events, workshops, field trips, and community engagements. I understand that these photographs, videos, and recordings may be used for the following purposes:

Website and social media platforms.
Marketing and promotional materials.
Newsletters and publications
Educational and training purposes
Community outreach and fundraising efforts
Other organizational communications.

I understand that no compensation will be provided for the use of these photographs, videos, or recordings. I further acknowledge that all media captured shall become the property of Heels & Ties Too Success Inc. and may be used without further notice or approval. I release and hold harmless Heels & Ties Too Success Inc., its officers, directors, employees, volunteers, sponsors, and partners from any claims, demands, or liabilities arising from the use of such media.

What are some of your personal or career interests? Please tell us about your hobbies, activities, talents, career goals, or areas of interest. (Examples may include entrepreneurship, technology, sports, arts, music, leadership, public service, healthcare, education, construction, finance, or other interests).

If you are ages 16 and older and have an opportunity to receive an internship what would you love to do? (Type your answer below👇)

Will your child need transportation home after the day camp program ends each day?

Please Sign Below:

Financial Aid Scholarship

Participants Details

Emergency Contact Information

Education

Photo, Video & Media Authorization

Youth Personal Interest

Transportation Needs

Signature

Official Use Only