Name *

First Name

Last Name

Phone

(###)

###

####

Parent/Guardian Name *

First Name

Last Name

Phone Number *

(###)

###

####

Emergency Contact *

First Name

Last Name

Phone

(###)

###

####

Media Equipment

Do you own or have access to any of the following? Check all that apply.

Laptop

Desktop Computer

Iphone or Android

Camera

Editing Software

Parent/Guardian Section *

Do you give permission for your child to participate in this program and for their work to be shared publicly (ex: community showcase, online platforms)?

Yes

No

Photo/Video Release Consent (Optional) *

Do you grant permission for your child to be photographed/recorded during the Video Production Program? Photo's and video's may be used by Heartworkers Union for: Program documentation reporting, sharing with donors, community partners and promotional materials (flyers, website, social media, newsletter.) Your child's full name will not be publicly shared without additional consent.

Yes, I give permission.

No, I do not give permission.