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MIRROR Project Registration
Registration to be filed out by parent or guardian.
Contact Information
Student Name
*
First Name
Last Name
Email
*
Verify Email
*
Parent/Guardian Name
*
First Name
Last Name
Email
*
Verify Email
*
Address
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Phone
Media Release
*
I hereby grant Real Images, In the absolute and irrevocable right and unrestricted permission to use photos/videos taken of my student in which they may be included with others, and to use, re-use, publish and re-publish the same in whole or in part, individually or in conjunction with other photos/videos and in conjunction with any media now or hereafter known, and for any purpose whatsoever for illustrations, promotion, art, editorial, advertising, and trade, or any other purpose whatsoever without restriction.
Yes, I consent
No, I do not consent
Mental Health Support
*
I give permission to Real Images and all team members affiliated with the organizations to dialogue and engage my student with mental health professionals as it relates to the topics of the MIRROR Program sessions
Yes, I consent
No, I do not consent
In Case of Emergency
*
I give permission to Real Images and all team members affiliated with the organizations to give my student medical attention in the case of minor or major emergencies, and contact the emergency contact listed on the file associated with the school/ after-school program partnering with Real Images.
Yes, I consent
No, I do not consent
Medical Conditions
Please list any medical conditions, including food allergies, and medications workshop facilitators should be aware of: