New HIGH SCHOOL STUDENTS ENROLLMENT FORM

HIGH SCHOOL STUDENTS ENROLLMENT FORM

Course of study you are interested in:

(Choice does not guarantee enrollment)
Enrollment in any program is subject to availability and meeting certain eligibility requirements.

Today's Date:

Class of Interes - High School

*If you signed up for an art or tech class and would also like to participate in our career mentoring program, please check here:

Yes No Not Selected

Last Name

First Name

Middle Name

Pronouns

Birth Date

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Street Address

City, State

Zip Code

Household Income

Neighborhood

Cell Phone

Home Phone

DEMOGRAPHIC INFORMATION

Your response to the following Questions are very helpful because they allow us to demonstrate to our funders that we serve diverse populations and they help us prepare appropriate programming to meet the needs of diverse learners. However, you may select "choose not to respond" as your response.

Current grade OR highest level of education completed:

School Name:

CPS/Student ID# (if applicable):

Gender

Are you a person with a disability?

Disability Description

Housing

Do you or anyone in your house hold receive goverment assistance?

If yes, indicate which services

Were you born in the US?

Primary Language Spoken at Home

Do you identify as LGBTQ+?

Do you or did you have an IEP while in school?

Did you or do you qualify for Free or Reduced Priced Meals while in school?

Have you ever been arrested? While a criminal background will not automatically exclude you from our programs, certain offenses will bar you from participation in our program.

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PARENT/GUARDIAN INFORMATION

Guardian Name

Relationship

Guardian Cell Phone

Guardian Home Phone

Work Phone

EMERGENCY CONTACT INFORMATION

Contact Name

Relationship

Cell Phone

Home Phone

Work Phone

Email Address

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Alternate Contact

Alternate Contact Relationship

Alternate Contact Phone Number

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Are you or your Family Member Employed at CHICAT?

Yes No Not Selected

CHICAT Employee Family Member Name - Please put N/A if you answered no to the question above.

How did you find out about CHICAT?

What special needs or considerations should CHICAT staff know about this student prior to enrollment?

Why do you want to be in this program?

Comments / Questions if any (Optional)

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CONSENT AND RELEASE

I consent to interviews, photographs, and audio and video recordings of myself (collectively, “Personal Images” I grant the Chicago Center for Arts Technology (CHICAT) and the Department of Family and Support Services (DFSS) irrevocable right to use, reproduce (whether through digital copying, photography, audio, and video recordings, or any other means), release, publish, transmit, distribute, exhibit, and/or display in any and all forms of media (whether existing or future, and whether in whole or in part) and in any and all manners, including (1) any or all of my artwork that is created at or through CHICAT and DFSS, (2) any or all of the Personal Images, and (3) my name and likeness. The preceding consents are given for and limited to CHICAT and DFSS’s activities as a non-profit institution. Such activities may include, without limitation, news articles, telecasts, webcasts, press releases, education, fundraising, marketing, advertising, and research. Such activities may be performed by CHICAT or CHICAT’s employees, agents, affiliates, partners, assignees, licensees, or designees. I waive all rights to inspect or approve any uses that may be created under the preceding paragraph, or the use to which any of the materials may be applied. I waive the right to compensation by, through, or under CHICAT for any uses that may be created under the preceding paragraph. I agree that Personal Images and all other originals thereof shall constitute CHICAT’s sole property, with the full right of disposition in any manner whatsoever. I release, discharge, and agree to hold harmless CHICAT, its agents, affiliates, partners, assignees, licensees, and designees, and all persons acting under its/their authority from any and all claims whatsoever in connection with the use of the materials as described in the first paragraph above. I certify that I either (a) am 18-years old and legally competent to execute this Consent and Release or (b) am under 18-years old and have the consent of my parent or guardian to execute this Consent and Release. I understand that the terms herein are contractual and not a mere recital, that this instrument is legally binding, that I have voluntarily signed this document, and that CHICAT is relying on this Consent and Release to perform the activities described in the first paragraph above. I have read this Consent and Release and am fully familiar with its contents.

READ AND SIGN

(If student is under 18 please have Parent/Legal Guardian sign.) My signature below indicates that I have read, understood, made correct, and completed statements on this application and any supplements to it. I understand that any omission or false statement made by me will result in disqualification, or discharge from program.

Student Signature:

Date

Parent/Guardian Signature(if student is under 18 years old):

Date

Enter the above code

Required