Want to Use Media to Make a Difference? Wide Angle Youth Media s Summer Video Production Workshop

Transcription

1 Want to Use Media to Make a Difference? Wide Angle Youth Media s Summer Video Production Workshop is an intensive 2-week media production program for Baltimore High School students. In the workshop, young people ages will: Learn basic video production skills Work in teams to create short video projects Earn stipends or service learning hours for participating. WHEN? July 9, 2012 July 19, 2012, Mondays-Thursdays, 1:00pm-5:00pm WHERE? Wide Angle s office at Miller s Court, 2601 N. Howard, #160, Baltimore, WHO? Baltimore City youth ages COST: FREE! Students will receive $5 for each day of participation upon successful completion of the program.* HOW? Fill out the attached application and return to Wide Angle by June 29, Application can be scanned and ed to info@wideanglemedia.org or mailed/dropped off at 2601 N. Howard, #160, Baltimore, MD, * Successful completion requires on-time arrival and full attendance for at least 6 of the 8 classes. Students may choose to receive service learning hours instead. About Wide Angle Youth Media Wide Angle Youth Media is a 501c3 non-profit that provides Baltimore youth with media education to tell their own stories and become engaged in their communities. Through after school programs, community events, our annual Youth Media Festival, and our youth-run television show, Wide Angle strives to make media make a difference. Since its founding in 2001, Wide Angle has worked with over 2,350 Baltimore City young people who have produced over 85 videos on topics including environmentalism, school bullying, identity, gang activity, education reform and teen parenting. 1

2 Student Application Name Age School Why are you interested in learning video production skills? (Please write at least two sentences) Do you have any video production experience? None A little Some A lot I m an expert If yes, please tell us more about your experience: 2

3 Permission and Release Form I, give my permission for (Parent/Guardian Name) (Youth s Name) to participate in any and all activities of Wide Angle Youth Media s Summer Video Production Workshop. I am aware that my child will learn how to use media production equipment, and have their own image and voice recorded, in the process of learning how to produce media messages, which may be distributed publicly. I understand that my child will go on supervised neighborhood walks within a ten block radius of the Wide Angle Office. On these trips my child will be filming or conducting research for their class projects, and I give permission for them to participate in this activity. I understand my child will be exposed to certain risks that by nature and location of these activities cannot be controlled. I agree to release and forever discharge Wide Angle Youth Media, their boards of directors, volunteers, employees and agents from any and all liability, and claims in any way connected with my child s participation in Wide Angle s Summer Video Production Workshop. I grant Wide Angle Youth Media permission to copyright and use, reuse, publish, and re-publish the image, voice, and likeness of my child, as well as any writing, drawing, or other media produced by my child, for inclusion in the Summer Video Production Workshop, and permit Wide Angle Youth Media to use said media for education, promotion, and other related purpose in print, video, on the web, and all media. I waive any and all rights to approve the final product or limit its distribution. Parent/Guardian's Printed Date Parent/Guardian s Name Signature Medical Release I permit my child to receive emergency medical services if necessary by a local hospital. I understand that any medical expenses will be directly billed to my insurance company or me. Wide Angle is not obligated for the cost, but has my permission to procure services for my child. Parent/Guardian Signature Name of Insurance Company Please list any allergies or medical conditions we should be aware of: 3

4 Demographic Information The following information is required by the program s funders in order to better understand the populations the program serves. This information will be kept confidential. PLEASE CIRCLE OR CHECK YOUR ANSWERS TO THE FOLLOWING QUESTIONS: Select the race that best describes your child: Select the status of your child s family: African American Hawaiian or Asian Pacific Islander Bi-Racial Native American Caucasian Other Hispanic Multi-Racial Single Parent Mother Single Parent Father Two Parent Household Legal Guardian Relative Legal Guardian Non Relative Other Relative Other Non Relative Is your child entitled to free or reduced-cost lunch? Is your child currently homeless? Is your child or your immediate family currently receiving TANF? (Temporary Assistance to Needy Families ) 4

5 Participant Information (PLEASE PRINT CLEARLY AND FILL OUT COMPLETELY) First Name Middle Initial Last name Nick Name Address Street Address Apt# City State Zip Birth Date (mm/dd/yy) Age Gender Race/Ethnicity Student ID Number (PIF #) School Grade in Fall 2012 Home Phone Cell Phone Parent/Guardian Information Parent/Guardian Name Street Address Zip Relation to Child Home Phone Cell Phone Occupation Place of Employment Emergency Contact Name Relationship to Participant Emergency Phone Are you interested in applying for a transportation scholarship? (Limited Availability) YES NO Would you like your child to receive a stipend ($5 per class) or service learning hours? Service learning hours are necessary for high school graduation for Baltimore City Public School Students. Stipend Service Learning If your child needs to leave class early, he/she: May walk home alone May take public transportation alone Must be picked up, please call As a parent or guardian would you like to? (Check all that apply) Join a parent advisory committee Volunteer in the office Assist with Fundraising Efforts Chaperone a field trip Make a financial contribution Serve on an Event Committee 5