Application Form

* denotes a required field.

Name:*

Reservation:*

Address:*

City:*

State:*

Zip:*

Home Tel #:*

Cell #:*

Age:*

Gender:*
 Male Female

Grade (if applicable):

Shirt Size:*

School (if applicable):

Email:*

Which of the following tracks listed below are you most interested in?*
 Broadcasting Graphic/Web Design Newspaper

Please answer the following questions:

How did you hear about the workshop?*
MailSeminole ChannelEmailFacebook/TwitterWord of mouth

Do you wish to pursue a career in the media field?*
 Yes No

If yes, which field and/or fields?
 Broadcasting Graphic Design Journalism Production Other

What would you like to accomplish by participating in this workshop?*

What interests you most in the broadcasting/graphic/web design/newspaper fields?*

Do you have any experience in media related arts?*
 Yes No

If yes, please explain:

Are you looking for additional opportunities after the workshop is completed?
 Internship Career Continued education Other

Parental Consent

Parent/Guardian Name:*

Will you be a chaperone at this year’s workshop?*
(If yes, please contact Donna Mason at 954-985-5700 or email: DonnaMason@semtribe.com)
 Yes No

Are there any medical allergies or information that we need to be aware of? If yes, please explain below:

Emergency Contact Numbers:*
Number 1:

Number 2:

I give permission for my son/daughter to attend the 2013 Seminole Youth Media Production Workshop being presented by Seminole Media Productions Department. (must be checked to submit the form)