Name:______________________________________________________   DOB:__________________________________________

Phone #: ____________________________________   Email:_______________________________________________________

Time involved in Mic Check: _____________________________________________________________________________

Other commitments (job, school, etc.) (*Note- workshops are TBD, but there will be additional open mics and other youth related events to participate in): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Past experience with youth and poetry (these two items do not have to be related. If you have worked with youth, but not in relation to poetry, still feel free to share both.): ________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Would you be willing to create your own lesson plan and lead a workshop?    Yes       No

I verify the above information to be true and factual. I understand that by working in conjunction with Mic Check Poetry, a 501c3 non-profit and CSISD, I must behave myself accordingly, in a professional and appropriate manner while working with the youth.

Signature: ________________________________________________ Date:________________________________________