Student Name *

First Name

Last Name

Student Gender

Which of the following best describes you? Select all that apply.

Female

Male

Non-binary/third gender

Prefer Not to Say

Other

Student Race/Ethnicity

Which of the following best describes you? Select all that apply.

American Indian/Native American or Alaska Native

Asian or Asian American

Black or African American

Hawaii Native or Pacific Islander

Hispanic and/or Latinx

Middle Eastern or North African

White

Prefer not to say

Multiple or some other race, ethnicity, or origin

Student Phone *

(###)

###

####

Parent or Guardian Name *

First Name

Last Name

Parent or Guardian Phone *

(###)

###

####

What is your birthday? *

MM

DD

YYYY

Please confirm who is completing the permissions section of this form. *

I am 18 years of age or older.

My child is under 18 years of age and a parent or legal guardian is completing this section of the form.

Online Participation Permission *

Yes, I give permission for my child to have access to Zoom, Google Classroom, Google Meet, Google Docs, audio, videos, and websites relevant to the curriculum.

No, I do not give permission for my child to have access to Zoom, Google Classroom, Google Meet, Google Docs, audio, videos, and websites relevant to the curriculum.

Agreement to Participate *

I agree to allow my child to participate in the Young Writers & Leaders program.

Yes

No

Transportation *

The Telling Room does not provide transportation for students to and from this program. The Telling Room is able to offer bus passes to students who are enrolled in a school that is outside of the Portland Public School system. Please share what your primary mode of transportation to The Telling Room will be.

I will walk/bike to The Telling Room

I will take the bus to The Telling Room

I will be dropped off at The Telling Room

I will drive myself to The Telling Room

Other

Do you need a Telling Room provided bus pass in order to get to The Telling Room? *

Yes

No