Paint HerStory Registration - For A Real Change

Youth's First Name*

Youth's Last Name*

Preferred Name

Preferred Pronouns

Current Grade in School*

School Attending*

Current City/State*

PARENT / GUARDIAN INFORMATION

Parent/Guardian's First and Last Name*

This should be the primary contact person(s) for the youth.

Parent/Guardian Mobile Number(s)*

Email Address (of Primary Contact)*

Enter Email Confirm Email

This will be used to send Living as Leaders details and updates.

If you prefer youth to get email updates, please add email address here.

Mailing Address (Street/City/Zip Code)

PARTICIPATION FORMAT & EVENT SUPPLIES

In-person participation has reached capacity, but you can still participate virtually via Zoom. If you participate online, please obtain the following: canvas (at least 8x10), acrylic paint brushes, and acrylic paint. You may do this virtually with watercolor brushes and watercolor paper if you prefer.

Supplies will be provided to those who participate in-person. Youth who participate online will be responsible for their own supplies.*

Yes, I plan to attend virtually and will have the necessary supplies to participate.

Participation Waiver and Consent

Consent*

I consent

By selecting "I consent," as a parent/guardian, you acknowledge that you understand that the youth registered on this form will be participating in the "Paint HerStory" event by For a Real Change and Light of Chance. By agreeing here, you agree that photos taken, screenshot, or submitted, and video recorded during this program may be used for promotional purposes by For a Real Change, Inc. or Light of Chance, Inc.

I understand that if I attend the in-person event, I will sign a separate consent form that includes CDC guidelines.

By agreeing, you also voluntarily, for yourself and Minor, accept and assume full responsibility for any risks of participation in the "Paint HerStory" program.