Wild Card Participants for Visual Poetry Jam

Your Name *

First

Last

Your Age (If you are a student)

eMail *

Email

Confirm Email

Your Mobile Phone Number

So we can contact you if we have any issues with your registration.

Name of Parent/Guardian (in the event of an emergency) *

Phone number for Parent/Guardian (in the event of an emergency) *

School Year *

Name of Town/City or Area you live in *

Region where you live *

If you would like to share any Social Media or Web Sites where we can see your art, please feel free to drop links here (Optional)

Name of your School you attend or if you are a homeschooler *

How do you intend to take the course?

Please upload a permission slip (signed by your parent or guardian if under the age of 16)

Click or drag a file to this area to upload.

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