Student First & Last Name *

First Name

Last Name

Birthday

MM

DD

YYYY

What's your phone number? *

(###)

###

####

*

I have obtained permission from my parent or guardian to partake in this program.

Phone number of parent or guardian *

(###)

###

####

Have you or your family ever experienced any of the following: gender based violence, racial discrimination, incarceration, foster care, undocumented or citizenship status in transition, workplace discrimination, microaggressions, homelessness? *

Yes

No

Maybe/Not Sure

Chose not to answer

Have you or your family ever experienced any of the following: a sensory impairment (vision or hearing), a mobility impairment, a learning disability (e.g. ADHD, dyslexia), a mental health disorder, a disability or impairment not listed here?

Yes

No

Maybe/Not Sure

Chose not to answer

According to Covered California income guidelines and salary restrictions, if an individual makes less than $47,520 per year or if a family of four earns wages less than $97,200 per year, then they qualify for government assistance based on their income. Is your family low-income?

Yes

No

Maybe/Not sure

Chose not to answer

How would you describe your learning style:

Visual learner: I need to read along when I hear a story or while in class. I learn best with pictures and videos. B. kinesthetic learner: I learn best while doing something interactive, like a game or science experiment.

Auditory learner: I’m really good at remembering songs. I like to read out loud or hear it read by others, it’s how I recall books best.

Kinesthetic learner: I am really good at absorbing information best through touch, movement and motion.

More than one above.

I’m not sure.

Do you watch TV or films?

Yes

No

What is your preferred social media platform?

YouTube

TikTok

Instagram

Facebook

I don't use social media

Other

I understand and have the availability to attend to all the scheduled meetings at the times and dates described in this application form. *

Yes

No

Maybe

I request a letter of recommendation upon final completion of this program.

Yes

No

Maybe

I understand I will receive a Certificate of Participation for arriving on time to all sessions. *

Yes

No

Maybe

I am interested in being part of the film, TV, news or entertainment industry.

Yes

No

Maybe

I have taken a film, theater or storytelling class before.

Yes

No

I am interested in improving my public speaking skills.

Yes

No

Maybe

I am applying with a friend.

You and your friend need to submit an application form each.

Yes

No

How did you hear about this workshop series? *

Website

Friend

Justice4Sister Instagram

Justice4Sister Twitter

Justice for My Sister Facebook

Other account social media, if so, which one,

Other organization, if so, which one.

Other.