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Registration for 2019 Amherst Media Youth Environmental Workshop
Registration for Summer 2019 Amherst Media Youth Environmental Justice Workshop participants
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Email
*
Your email
Name participant prefers to be called?
First Name
*
Your answer
Last Name
*
Your answer
Participant cell number
*
Your answer
Participant home number
Your answer
Name of Parent / Guardian
*
Your answer
Cell phone number of Parent / Guardian
*
Your answer
Email address of Parent / Guardian
Your answer
Emergency Contact Person (Relationship to participant) & Phone: *
*
Your answer
Any health issues we should be informed about or allergies? Please describe.
*
Your answer
In case of emergency, do we have permission to bring participant to the nearest hospital?
*
Yes
No
Physicians name and phone number
Medications to administer in case of an emergency such as epipen, asthma inhalers, BENADRYL®, aspirin, etc.?
Your answer
Home Address
*
Your answer
Town
*
Your answer
State
*
Your answer
Zip
*
Your answer
Are you or someone in your family a member of Amherst Media?
No
Yes
Would you like to become a member of Amherst Media at the student rate of $25?
Go to
https://amherstmedia.org/civicrm/contribute/transact?reset=1&id=1
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A copy of your responses will be emailed to the address you provided.
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