Raven Words Summer Youth Writing Workshops
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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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| Email
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| Course registered and paid
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| Jumpstart Your Write Brain, July 18-22, 1-4 p.m (ages 12-14) Comic Adventures, July 25-29, 1-4 p.m (ages 10-13) Ravens and Tigers and Bears, July 25-29, 9 a.m.-noon (ages 10-12) For "Your Alaska Online Travel 'Zine," please complete the Scholarship Application, which will serve as your registration.
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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.
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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 and the Alaska State Writing Consortium, 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 Alaska State Writing Consortium 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 understand that registration fees are nonrefundable unless a child from the waitlist can fill the spot vacated. I certify that all information provided here is true and correct.
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Image Verification
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