Student Participant Registration Form
PEN America’s Freedom to Read Student Summit - Northern California
Saturday, September 30, 2023 | 12:00pm - 4:00pm
The Mix at Main | San Francisco Public Library
100 Larkin St, San Francisco, CA 94102
415-557-4404 | https://themixatsfpl.org

This event is open to students in any level of high school and is free to attend. Snacks and refreshments will be provided. Capacity is limited so register as soon as possible. If you have any questions, please contact us at institute@pen.org.

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First Name *
Last Name *
Date of Birth *
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Current School Name *
Current Academic Year *
Gender (Please select all that apply)
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Race/Ethnicity (Please select all that apply)
Do you have any accessibility requirements?
Do you have any food allergies, or dietary restrictions?
Would you like to opt-in to regular email updates from PEN America about opportunities for students including job openings, fellowships, essay competitions, and certification institutes? *
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Would you like to opt-in to regular email updates from the San Francisco Public Library and the Mix at SFPL? *
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MEDIA RELEASE WAIVER:

PEN America, the San Francisco Public Library, and UC Berkeley student videographer Alyssa Poole would like to take photos and videos of the event to share online on our websites and social media. We'd greatly appreciate if you could please read and accept the Media Release Waiver below so that we can share and promote similar opportunities to more students. For attendees ages 17 and under, signing the waiver below confirms that you have permission from your parent/legal guardian:

"I authorize PEN America, the San Francisco Public Library, and Alyssa Poole to photograph, film, broadcast, record or otherwise document and edit my image, likeness, and voice in connection with the Program (“Freedom to Read Student Summit - Northern California” on Saturday, September 30, 2023). I grant to PEN America, the San Francisco Public Library, Alyssa Poole, and their successors, assignees and licensees the right to use photos and recordings from the program or any part thereof, for, but not limited to, broadcasting, merchandising, advertising, promoting and marketing of PEN America, the San Francisco Public Library, and its activities and for educational purposes via radio, television, video, the internet, podcasts, publications (print and digital) or by any other means now known or hereafter devised. I waive any right to royalties or other compensation arising from or related to the use of the photos and recordings."

Please accept by electronically signing below:
DISCLAIMER:

PEN America's Freedom to Read Student Summit is an educational program. Nothing from the event and its workshops constitutes legal advice. While PEN America and San Francisco Public Library stand strongly against book banning and censorship, we do not condone or encourage violence or unlawful behavior.
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