Name of Student *

First Name

Last Name

Student's Phone Number *

(###)

###

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Have you participated in CFI Education programs before? *

Yes

No

Parent or Guardian *

First Name

Last Name

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone *

(###)

###

####

Alternate Phone

(###)

###

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Do you have any allergies or dietary restrictions? *

Yes

No

My Place | My Story is a fun but rigorous program that requires both discipline and a variety of skill sets such as writing, public speaking, collaborating and troubleshooting. Do you have any special needs or learning challenges you’d like us to be aware of that might impact your participation in the program? No one will be turned away based on their learning requirements, but knowing about them in advance is a great help for our instructors in preparing for your participation. *

Yes

No

Will you be able to arrange your own transportation to the workshop in downtown San Rafael each day?

Yes

No

I understand that my application for the My Place | My Story program requires that: *

I will create a personal narrative film about my own life experiences, not a fictional script.

I will attend all 5 days of the workshop, from 10am-5pm