TAG- Future Selves Registration Form
Please fill out the following questions, we want to provide the best experience for your young creative possible. Thank you for your time.
Young Creative's Name *
Your answer
Name of Parent or Guardian *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Has your child participated in a Squeaky Wheel education program previously? *
Are you a Squeaky Wheel Member? *
Does your Child have any food allergies? *
If so please explain.
Your answer
Are there any other cognitive or behavioral issues that we should be aware of? (All information is confidential)
Your answer
How did you hear about our workshops? *
I grant to Squeaky Wheel/Buffalo Media Resources the right to take photographs of me and my family in connection with this event or workshop. I authorize Squeaky Wheel/Buffalo Media Resources, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Squeaky Wheel/Buffalo Media Resources may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. *
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