Photovoice Art Workshops Registration

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Welcome to Tobacco-Free Partnership Covina/West Covina Photovoice Art Workshops enrollment.

1. To begin fill out the information below.
2. Upon sending us this form you will receive an e-mail with the participant consent and image release forms.
3. Your signature is required prior to attending the first session.
4. Return the consent forms by:
(1) By printing, signing and returning by USPS mail:
Tobacco-Free Partnership Covina/West Covina
223 E. Rowland St.
Covina, CA 91723

OR computer or phone option:
(2) Printing, signing, scanning a copy of the forms with your original signature. Only an original signature, NOT a digital signature stamp, will be accepted. (PDF file preferred)
Options to create PDF by phone : Android phone download Tiny Scanner APP
iPhone download: Scanner App

Contact us if you have any questions:
Elsa Greno, Project Coordinator | 626.608.8314 cell | elsag@socialmodel.com

We look forward to seeing you soon in the Photovoice Art Workshops.

Email *

What grade are you in? *

Option 1

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Untitled Title

First Name *

Last Name *

Mailing Address *

City and State *

If you chose N/A Please provide your City and State: *

Zip Code (Covina) *

Zip Code (West Covina) *

If you chose N/A Please provide your Zip Code: *

Phone Number *

Emergency Contact - Name and Phone Number (optional but highly recommended in case an emergency arises)

I am over 18 years of age *

Yes

I will sign and return consent forms for images being shared during the workshops by Email or USPS mail. *

Yes

Required

I agree to attend the weekly 4 Photovoice sessions. They will be 75 minutes each via Zoom. (Attending 3 sessions will earn you a $30 gift card) *

Yes

Maybe

Check Available Dates and Times. Click up to 3 times that you prefer.

4:00 PM - 5:15 PM

5:00 PM - 6:15 PM

6:00 PM - 7:15 PM

Tuesdays

Thursday

The Tobacco-Free Partnership Covina/West Covina is a program of Social Model Recovery Systems

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