2017 - 2018 Workshop Registration
First Name *
Your answer
Last Name *
Your answer
Age *
Charter Schools
Select from this list if you attend a Philadelphia Charter School
High School
Select from this list if you are currently enrolled in a Philadelphia Public High School
Middle School or Elementary School
Select ONLY if you are currently in elementary or middle school.
Universities
Select ONLY if you are currently enrolled in a University.
School Not Listed? Write it here.
Your answer
Grade *
(If not enrolled in school, choose "currently not enrolled")
Zip Code *
(i.e. 19144)
Your answer
Your Phone Number
(Leave blank if you don't have one)
Your answer
Your Email Address
(If you don't have an email address, leave it blank)
Your answer
Emergency Contract *
(First and Last Name)
Your answer
Emergency Contact's Relationship to You *
(mom, dad, etc.)
Emergency Contact's Phone Number *
Your answer
Race
(Optional - Check all that apply to you. Info is confidential and used for PYPM data collection.)
Gender
Optional - info is strictly confidential. Your name will never appear publicly. Only used for PYPM data collection.
Sexuality
Optional - info is strictly confidential. Your name will never appear publicly. Only used for PYPM data collection.
How long have you been a member of PYPM?
(how long you have been attending workshops, slam league, and or youth night).
How did you hear about PYPM? *
What are you looking for a PYPM? *
Required
Are your parents or guardians interested in getting involved in PYPM? *
If your parents and guardians are interested in getting involved, how would they like to be involved?
How can we best get in contact with them?
(type in their name, relationship to you, and email address and/or phone number)
Your answer
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