Peace thru Culture Global Break: Winter 2020 - REGISTRATION FORM
About Peace thru Culture Global Break

Dates: February 17 -21, 2020 - DAILY 9AM - 4PM
Ages Accepted: 8-12 & 13-16
Location: 699 Maine Avenue, SW, Washington DC 20024 (RIVERSIDE BAPTIST CHURCH)

The week long Global Break is a Culture and Arts program that highlights local DMV culture, South Africa and Argentina through an interactive, hands-on program. In addition, youth select a track to follow for the week which includes Urban and Hip-Hop inspired Master Dance Classes, Percussion & Voice and Mixed Media Art.

Peace thru Culture has hosted PtC Corps and Camps for more than a decade.

Our Team
PtC Global Break Artist in Residence
Our professional Music Teacher, Mr. Ricardo James works with DC Public Charter Schools throughout DC, holds a Master's Degree in Music and provides private lessons to some of DC's most talented youth.

Lindsay Renee Benjamin is a seasoned Dance instructor with 10 years of experience teaching hip hop and ballroom to youth and adults of various skill levels.

Michaela Champion is multi talented youth development worker and will lead yoga classes, and the Mixed Media Art classes

PLEASE COMPLETE THE APPLICATION BELOW. ALL APPLICANTS MUST BE A DC RESIDENT AND ATTEND A DC SCHOOL TO APPLY FOR THIS PROGRAM. ONCE WE RECEIVE YOUR APPLICATION AN ACCEPTANCE LETTER WILL BE SENT WITH FURTHER DETAILS.

SCHOLARSHIPS ARE AWARDED ON A FIRST COME FIRST SERVE BASIS.
Email address *
Section 1: Youth Information
Youth's Full Name *
Your answer
Address *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
School Name *
Your answer
Grade Level *
What ethnic group does the youth identify with?
Section 2: Arts Track
In this next section, please select your 1st, 2nd and 3rd choices by placing a 1, 2 or 3 underneath each description. Please read each description clearly before selecting your choices.
The Voice: No one is judged. Let our music teacher help you reach any note through this fun multicultural vocal experience. *
Your answer
Urban Dance: No experience required. Learn and share urban moves from DC and around the world. *
Your answer
Mixed Media Art: Great for artists, poets and explorers of new art forms. *
Your answer
Section 3: Essay
The youth must complete this section. Students will be selected based on this short essay and information provided below.
In 50 words or less, let us know why you would like to attend the Peace Thru Culture Global Winter Break. *
Your answer
Section 4: Parent/Guardian Information
This section is about the student's parent/guardian.
Parent/Guardian #1 Name *
Your answer
Parent/Guardian #1 Address *
Your answer
Parent/Guardian #1 Phone Number 1 *
Your answer
Parent/Guardian #1 Phone Number 2
Your answer
Parent/Guardian #2 Name *
Your answer
Parent/Guardian #2 Address *
Your answer
Parent/Guardian #2 Phone Number 1 *
Your answer
Parent/Guardian #2 Phone Number 2
Your answer
Section 5: Emergency Contact Information
Emergency Contact Name *
Your answer
Relationship to Emergency Contact *
Your answer
Emergency Contact Phone *
Your answer
Section 6: Youth's Medical Information
Insurance Company Name *
Your answer
Insurance Card Name *
Your answer
Name of Primary Card Holder *
Your answer
Allergies or Special Requirement *
Your answer
Epi Pen Requirement? *
Section 7: PARENT STATEMENT
Please read the following statements.
I hereby state that the youth participant stated above is in good health and physical condition and is capable of participation in the PtC Global Winter Break Program - Peace thru Culture, and designated field trips throughout the week of February 17-21, 2020 between 9am – 4pm. *
Required
Waiver of Liability and Hold Harmless: As the legal parent/guardian specifically release Peace thru Culture, its students, agents and employees from any claims or liabilities of any kind whatsoever, arising from or related to my participation in these activities. *
Required
Photo Release: I agree to grant to Peace thru Culture and its authorized representatives permission to record on photography film and/or video, pictures of my participation. I further agree that any or all of the material photographed may be used, in any form, as part of any future publications, brochure, or other printed materials used to promote Peace thru Culture, and further that such use shall be without payment of fees, royalties, special credit or other compensation. *
Required
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