Nickelodeon Satellite Site Confirmation Form
Thank you so much for your interest in participating in our 2023 programming! 
Please fill out the following so we can bring free nick workshops to your site!
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Name of your Site, Program, or Group
 *
Site Representative First and Last Name *
Secondary Contact First and Last Name (optional)
City and State  *
Site Representative  Email
 *
Email will be our first point of contact. If the email bounces we will reach out via phone. If you prefer to be contacted via phone please note this in the further information.
Phone Number to use to contact you for updates 
(enter as  000-000-0000 )
 *
Is a text to this number ok? *
Which Sessions would you like to host at your site?
 *
Required
Any questions or further information you want us to know?
ACKNOWLEDGEMENTS AND AGREEMENTS
I am a representative of this site and I can confirm that we have the structure and legal clearance to either supervise young people or accommodate families at our site.

I verify that the information put forward is correct and valid for further communication.

I and the site I represent agree to participate with respect for the teaching artists, fellow students, and any affiliates with the program.

I acknowledge that I have the technical ability to accommodate and execute the virtual workshops including; access to the internet, zoom platform, and technical equipment which can screen and run zoom to a group of people.

I and the site I represent understand and take full responsibility and liability for hosting individuals in our space.

I and the site I represent understand and agree that Calibraska Arts Initiative / Arts with Others and its affiliates (including but not limited to Nickelodeon Animation Studio, etc.) are responsible for their sole purpose to provide a virtual educational service and is neither responsible nor liable for any situation at my site or incidents that may occur outside of that content.

I and the site I represent agree to these terms and those outlined in the Satellite Site Release Form
 *
PHOTO AND CREATIVE RELEASE

I hereby grant to the Calibraska Arts Initiative / Arts with Others and it's partners and or affiliates the irrevocable and unrestricted right to use, reproduce, publish artwork and other creative productions from the class/event, photos and video recordings of myself, our site, site staff, and or participants taken in the course of the Calibraska Arts Initiative / Arts with Others activity; and to use such photos for any lawful purpose, in any manner or medium, and to alter the same without restriction including promotional purposes.

I and the site I represent agree to the Photo and Creative release
 *
Participant Tracking
It helps us and Nickelodeon to track our reach as well as determine what our participant population make-up looks like.

As a satellite, we will depend on you to track some basic data of your participants. (# of participants, gender, race, and hometown population)

This can be something you fill out for all the workshops because you have a set group of students in your program or it can be on a case by case basis for the students that attend each workshop at your site.
DIGITAL SIGNATURE
By my eSignature verification below, I verify that I understand that electronic signatures are legally binding and have the same meaning as handwritten signatures. Pursuant to section 11.100 of Title 21 of the Code of Federal Regulations, this is to certify that I confirm that this electronic signature is to be the legally binding equivalent of my handwritten signature and that the data on this form is accurate to the best of my knowledge.

This Signature confirms and binds you and the student to the terms set forth in this document.
Representative Signature *
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