YouMedia Student Application

Student information:
First Name:___________________ Last Name:______________________ Middle initial:___
Gender :_____________ Ethnicity:______________ Grade:___ Age: ___
Birthdate:__/__/____
E-Mail:________________________ Cell:___-___-____________
Allergies:______________ Any other medical conditions we need to be aware of? Yes
No
If yes Please state details:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Emergency Contact information

First Name:___________________ Last Name:______________________ Middle initial:___
Relation:________________ E-Mail___________________ Cell Phone:___-___-____
Home Phone:
___-___-____
I hereby give my child permission to participate in YouMedia at the Portland Public
Library for the Spring of 2015.
Parent/Gaurdian Signature:______________________
Additional notes:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Funded by the US Institute of museum and library services through a grant to the Texas state library and archives commission.