Raven Words: Your Alaska Online Travel 'Zine
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| Student's last name
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| Student's first name
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| Grade student will enter in Fall 2011
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| Student 's age
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| Gender
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| Male Female
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| Parent/guardian name
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| Mailing address
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| City
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| State
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| Zip
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| Phone (mobile preferred)
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| Email
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| EMERGENCY CONTACT Name
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| EMERGENCY CONTACT Phone
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| Will anyone besides you be picking up child?
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| Yes No
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| If yes, who?
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| If yes, phone (mobile preferred)?
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| Does your child have any allergies we need to be aware of?
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| Yes No
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| If yes, please list:
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| Does your child take any medications we need to be aware of?
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| Yes No
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| If yes, please list:
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| How did you hear about Raven Words Summer Youth Writing Workshops?
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| What we should know:
| Is there anything we should know about your child in order to serve him/her better (attention deficit disorder, vision/hearing impairments, allergies, asthma, seizures, behavior problems, learning disabilities, etc.)? If so, please explain. Confidentiality will be maintained by Raven Words staff.
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| Release and waiver (initial)
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| For and in consideration of my child's participation in the Raven Words Summer Youth Writing Workshops, I attest that my child is physically and mentally capable of participating in group activities with an adult leader. My child's participation is voluntary and done at his/her/my own risk. For myself, my heirs, my administrators and executors, personal representative and my assigns, I forever waive, release, and discharge any and all claims and rights for damages or losses, whether monetary or otherwise, against 49 Writers, agreeing now and forever to hold these parties harmless, indemnifying them against all claims, judgments, damages, and costs. I agree to abide by all instructions from workshop leaders and agree to withdraw my child from the program if said leader in his or her sole judgment and discretion determines that my child should not participate because s/he poses a threat to the safety of him/herself or others or because s/he does not abide by instructions. I grant permission to 49 Writers and the to use any videotapes, photographs, motion pictures, recording, or any other record of my child and/or the workshop for any legitimate purpose, including publication of an anthology of student work. I certify that all information provided here is true and correct and that the Student Writing is the original work of the student. I understand that scholarships are awarded solely at the discretion of the Raven Words staff, and that the scholarship has no intrinsic or transferable cash value. If a scholarship is awarded, I agree to provide for transportation to and from Teen Underground at the Loussac Libraryl in Anchorage and to make sure my child participates fully or to notify Raven Words staff immediately if participation is not possible.
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| Online Publication: Name
| Student's first and last name may be published. Only student's first name and last initial may be published
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| Online Publication: Photo
| Individual photo may be published with student writing Group photo only with no individual identification
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| Parent or authorized adult signature
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| Student Writing: Show Us Your Alaska
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| What's best about living in Alaska? Give us your insider's perspective in 400 words or less. (Hint: type your entry in a word processing program and copy/paste it here). This must be the student's original work! You may also email a photo or illustration to accompany your work: 49writers@gmail.com. In the subject line: Raven Words Scholarship (your name).
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Image Verification
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