Student Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Student Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Parent or Guardian *

First Name

Last Name

Parent or Guardian Primary Phone *

(###)

###

####

Alternate Phone

(###)

###

####

Emergency Contact Phone Number *

(###)

###

####

PROGRAM *

NARRATIVE FILM PRODUCTION FOR TWEENS – IN PERSON July 15-19 & 22-26 | 10:00am–4:00pm | Ages 11-13 | $1900

YOUTH IN INDUSTRY LAB – ONLINE Wednesdays 10:00am–1:00pm PT | July 10-31 | Ages 14–18 | $400

PAYMENT

Credit Card

Check or Money Order via post (see details below)

Yes, I am applying for a scholarship

No, I am not applying for a scholarship