TTN: Media Making Application
Please complete this form to be considered for acceptance to the Teen Technology Network: Media Making program. If accepted, you will be expected to complete several other application components including a medical release form, transportation permission slip, media release form, report card release form, behavior agreement, and parent agreement.
Student Information
Student Name *
Student Date of Birth *
Student Email *
Student Home Phone Number *
Student Mobile Phone Number *
School Information
School Name *
Student Grade Level *
School Phone Number
Teacher or Counselor
School for previous school year (if different from above)
Parent/Family Information
Parent/Guardian Name *
Student Mailing Address *
Please include city, state, and zip code
Parent Mobile Number *
Parent Email *
Survey Information
Although the survey section is all optional, we strongly encourage applicants to provide the information requested. It helps us to report to our funders to continue to provide free programs.
Parent Occupation
Annual Household Income
Does the student or family own a computer at home?
If yes, how many?
If not, has the student owned a computer at home?
What is the condition of the home computer(s)?
Does the family have access to internet at home?
Student Statement
Please answer the following prompt in complete sentences. This section is to be completed by the student only.
Describe your interests in technology, media, and computers. *
Describe the role that technology, media, and computers has in your life now. *
I verify that I, the student applicant, completed the Student Statement section of this application, and no one else.
Please type your name below as an esignature affirming that the above statement is true.
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