Student First & Last Name
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First Name
Last Name
Age
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Birthday
MM
DD
YYYY
What's your email?
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What's your phone number?
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(###)
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Parent/Guardian Consent
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Name of parent or guardian who will sign participation agreement on your behalf
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Phone number of parent or guardian
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(###)
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Email of parent or guardian
What neighborhood do you reside in?
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Sylmar
Pacoima
San Fernando
Other. Please expand below
If you answered other, please tell us what neighborhood do you reside in:
What school do you attend?
What is your race/ethnicity?
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African-American/Black
Latino/Latinx/Mestizx
Asian/Pacific Islander
Caucasian/White
Native American/Indigenous
Middle Eastern/Arab
Bi-racial/Multiracial
Other
If other, please specify
What is your gender?
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Female
Male
Nonbinary
Transgender
Other
If other, please specify
What are your pronouns?
*
If other, please specify
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
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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?
Do you qualify to get free or reduced lunch?
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Can you explain what media literacy is?
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I often think about who creates the media I watch and what motivates them to create it.
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In general, I think representation of my community is accurate in the media (TV, film, podcasts, etc.)
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Why do you agree or disagree that representation of your community is accurate in the media (TV, film, podcasts, etc.)?
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In general, I think representation of women and girls is accurate in the media (TV, film, podcasts, etc.)
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Why do you agree or disagree that representation of women and girls is accurate in the media (TV, film, podcasts, etc.)?
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I am familiar with the concept of gender equality.
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I am familiar with the concept of advocacy
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How comfortable are you speaking publicly (for example, giving a speech)?
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How confortable are you approaching people you don’t know and engage with them in conversation?
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How comfortable are you telling a story from beginning, to middle, to end?
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How comfortable are you providing feedback to your peers?
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How comfortable are you handling conflict?
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How many times have you engaged in: activism?
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I believe that I’m the first to speak in a group setting.
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I believe that I’m often more quiet in a group setting
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How would you describe your learning style:
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I am interested in being part of the film, TV, news or entertainment industry.
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What is your main creative outlet?
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Have you made a film before?
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What is your favorite TV show, film, podcast, and/or YouTube account?
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What is one goal you have for participating in this filmmaking intensive?
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Are you interested in receiving information about additional enrichment opportunities?
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How did you hear about this workshop series?
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Website
Friend
Justice4Sister Instagram
Justice4Sister Twitter
Justice for My Sister Facebook
Other account social media,
Other organization
Other
If other, please specify
Program Stipend
