Participant Name
*
First Name
Last Name
Participant Email
*
Participant Age
*
14
15
16
17
18
19
20
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Are there any allergies or medical conditions that we should be aware of?
*
Preferred Pronouns
She/Her
He/Him
They/Them
Other
Please check one or more of the following groups in which you consider yourself to be a member:
What is your greatest strength when problem solving or collaborating with others?
*
How do you hope to grow from this weeklong challenge?
*
Describe a past experience you have had in social justice work OR explain how you hope to influence social justice in the future.
*
How did you hear about this sustainability challenge?
*
Social Media
Print Flyer
Email
From a friend/family member
From a community organization
Other
Video and Photo Release
*
As a parent or guardian of the minor mentioned above, I authorize the Collaborative Center for Social Innovation (“the Center”) to take and use visual/audio images of my child. Visual/audio images are any type of recording, including photographs, digital images, drawings, renderings, voices, sounds, video recordings, audio clips, accompanying written descriptions, and/or any other type of media now or hereafter known.
The Center may use and/or authorize the use of my child’s video/audio images and/or my child’s name in any manner or media without notifying me -- such as but not limited to, websites, publications, presentations, exhibitions, broadcasts, advertisements and/or posters.
I waive any right to inspect or approve the finished images, prints, or any electronic matter that may be used with them. I agree that all visual/audio images connected therewith are and shall remain the property of the Center. I release the Center, its employees, officers, trustees, administrators, successors and assigns from any claims, damages, or liabilities which I may ever have in connection with the taking of or use of my child’s visual/audio images and/or my child’s name. I have read this release before checking a box below. I understand its content and I freely accept its terms.
