Amped Studio After School Fall 2022 at Tara High!
Art Based Civic Engagement at Amped Studio After School!
2:30-4:30 pm

TUESDAYS, WEDNESDAYS, & THURSDAYS 
Your mind and voice matters! Students will be able to partake in Art Based Civic Engagement. This is an opportunity to express your concerns for what you believe is a problem in your community. You will engage in required research to explore solutions and turn your research into art! 


AMPED STUDIO ENROLLMENT REQUIREMENTS
Complete Enrollment Application and submit enrollment forms (stipend, transportation, and student handbook agreements).
Students may only attend Amped Studio after school if they are passing all of their core classes. No student may attend if they currently have an ‘F’ in the subjects of
Math, English, Science, or Social Studies.


WHY JOIN?
You will earn a $25 restaurant gift card, Amped Studio Hoodie, 
$50 Amazon Gift Card, and $150 after completing a total of four work cycles!
Snacks provided!
Transportation home by bus available, we got you!
Go on field trips & have some fun!
Set goals. You are worth it!
Make a difference in your community!
Let’s give what’s supposed to be gave!

START DATE: October 12, 2022

For more information contact Mr. Williams at zwilliams@humanitiesamped.org or stop by W-11 to speak to our staff.
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Last Name *
First Name *
School email *
Student cell phone *
Do you need transportation home from the program? *
If you need transportation, please write the address you will need to be driven to after the program. Include the STREET ADDRESS and the ZIP CODE.
Information about you
This information will help us know more about you.
Grade
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Gender
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Do you qualify for free or reduced lunch
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Race/Ethnicity - check all that apply
Parent/Guardian Information and Permission
This section is for your parent/guardian to give permission for you to participate. If you are 18 or older, you can fill out this information yourself.
Parent/Guardian's First and Last Name (or your own if you are 18+) *
Parent/Guardian's Cell Phone # *
Parent/Guardian's Email Address *
Name of Emergency Contact (other than parent/guardian) *
Phone Number/s of Emergency Contact (other than parent/guardian) *
If there are any medical or health conditions that Amped staff should be aware of for safety reasons, please explain here. Include food allergies or any physical or mental health needs the student may have. *
I consent to the above listed student participating in any programs or activities, either on or off campus. I acknowledge that participation in activities have inherent risks. I custodial guardian, assume that risk on behalf of my child/children and will indemnify and hold harmless Humanities Amped and The East Baton Rouge Parish School Board from and against all claims and demands on account of, or in  any way from, any accidental occurrence. In the event that my child/children should need further medical treatment while in the program, I give the staff permission to order x-rays, routine tests, treatments, that may require hospitalization, and necessary transportation. I understand that the staff may be unable to contact me at the time when medical treatment is necessary and therefore grant permission for them to seek and administer such treatment and medication prior to contacting me for further permission. I authorize payment of medical benefits to the health care provider for any services and the release of any medical or over the counter medications they deem necessary. I confirm that, to the best of my knowledge, my child/children is not allergic to any medications other than listed above. I hereby release the Humanities Amped and East Baton Rouge Parish School Board, its officers and representatives of all liabilities arising from this activity. *
As part of their participation, your child may be asked for their consent to be photographed, videotaped and/or voice recorded and for his/her name, image, likeness and voice to be used in Humanities Amped-approved photographs, videos, publications, internet, news and social media and web pages for special projects or publicity. Your child reserves the right to refuse to participate in being photographed, video taped and/or voice recorded, or to answer any questions or participate in any discussions that make him/her feel uncomfortable or embarrassed. I understand that neither Humanities Amped, nor the news media, has any obligation to air or publish the image, photos, videotape and/or voice of my child. I also understand that neither I nor my child will receive any monetary compensation for the rights granted herein. And I understand that my child’s appearance or the use of his/her voice in any publication, photo, internet or televised form does not confer any ownership rights on me or my child. *
Signature Verification
By typing my name and date below, I acknowledge the accuracy of my responses in this form.
Type your full legal name here, this serves as a digital signature *
Date of Signature *
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Follow Up Contact
Please feel free to contact us with any questions or concerns you may have. Our contact information can be found at www.humanitiesamped.org or by emailing zwilliams@humanitiesamped.org.
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