application summer 2019

First Name *

Last Name *

Parent/Guardian Full Name *

Physical Address

Street Address *

City *

State *

Zip *

Mailing Address

Mailing Address *

City *

State *

Zip *

Contact Information

Email Address *

Phone *

Preferred Contact Method *

Phone Call

Text

School *

Grade *

Birthdate *

Month

Day

Year

How did you find out about the HFAM Summer Camp? *

Poster Location

School Visited

Teacher Name

Other

Questions

Why do you want to be a part of the High Five Access Media summer camp, and what are you most excited about learning or doing? *

Do you have experience making media? If so, please describe this experience. If not, please describe an example of media you find interesting and how it inspires you to become involved in media. *

Please talk about any talent or skills you have from an experience at school, a job, or extracurricular activity that you would bring to the summer camp. *

Please describe an issue or story from your community that affects teens that you are passionate about. *

Demographics

These questions are optional, and will not affect your selection.

Gender

Race/Ethnicity

African, African-American, Black

Asian, Asian-American, Pacific Islander

Hispanic, Hispanic American, Latina/o

Native American, American Indian

Caucasian, non-Latino

Other (Please Specify Below)

Other

Do you have any physical/emotional conditions/special needs/learning disabilities that we should be aware of to help you have a successful and enjoyable experience?

Yes (Please Explain)

Explain

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application summer 2019