Registration Form and Information - to download form, see message below BlocK Code of Conduct

Please download the attached form or print this page. Send completed form to:
Writers Block 2008 Summer Program
300 State Street, Suite 313; New London, CT 06320

Questions? Call:
860.44BLOCK; writersblock2@gmail.com

Student Name:
Address:
Age (10-17):
Date of Birth (Month/ Day/Year)
Gender:
Home Phone:
Cell:
E-mail (if applicable):
School:

Mother/ Father/ Guardian:

Parent/Guardian Cell:
Daytime Phone:
E-mail:

Allergies/Medications:

Emergency Contact Name:
Relation:
Phone:

Does student have parent’s permission to leave the Writers Block on his/her own? Yes No

Talent (Circle all that apply)
Writing Dancing Singing Acting Art Musical Instrument ___________ Other: _______
Career/Academic Goal: (What/Who do you want to be when you are 26?)

I/my child, _______________________ hereby consent(s) that the Writers Block InK reserves shared-copyright of all written, musical and artistic material as a source of intellectual and potentially commercial capital that can be used to spawn other Blocks, be a source of revenue for continued non-profit programming; provide other learning institutions substrate for their own theatrical or other programs, and provide the Block participants with the opportunity to cite to future schools and/or employers their professional contribution(s) to Writers Block InK productions.

I hereby warrant that I have every right to contract in my own name in the above regard. I state further that I have read the above authorization and release, and that I am fully familiar with the contents thereof.

Student Signature: _______________________________________ Date: _________________

Parent Signature: ________________________________________ Date: _________________

If at any time medical treatment is necessary for my child, I give consent for treatment to be given. I understand every effort will be made to contact parent/guardian prior to emergency treatment. I agree to deliver my child to the instructor no earlier than 15 minutes prior to the start of the workshop and to pick up my child no later than 15 minutes after the workshop ends. I understand that Writers Block InK and its staff do not assume responsibility for transportation.

Parent Signature: ________________________________________ Date: ___________________
Payment

Fee $160.00 first child; $100 second child; 80 third child
Scholarship Requested in the amount of: _____________________ (enter amount here and complete scholarship application request form)

*Please note: The registration fee does not include additional costs associated with field trips.

Payment Amount Enclosed: _________ Check No:______ Date: _____________
Please make checks payable to “Writers Block InK”
Refund Policy: Full refund for withdrawal prior to June 30th ; $50 refund prior to July 7th ; No refund after July 7th

The BlocK Code of Conduct

1. RESPECT: Respect yourself, fellow BlocK members, families, audiences, BlocK leaders, teachers and community.

2. RESPONSIBILITY: Take responsibility for your actions; your role in BlocK performances; complete your writing/acting/dancing/singing/rapping on time; return all fundraising monies, costumes, and props to the BlocK; compensate for any damages you cause to property and/or performance space of/or entrusted to the BlocK.

3. REWARD: One of the final rewards for adherence to respect and responsibility includes participating in BlocK programs and performances on stages throughout the community.

4. REMOVAL: Violation of the BlocK Code may result in student’s/participants removal from all BlocK Programming. The BlocK Director reserves the right to remove any BlocK Code violators from all or portions of Block performances at her discretion.

Please download form and return to:
Writers Block 2008 Summer Program
300 State Street, Suite 313; New London, CT 06320

Questions? Call:
860.44BLOCK; writersblock2@gmail.com


CLICK ICON TO DOWNLOAD REGISTRATION FORM

     Scholarship Application - to download form, click icon at bottom of page

Please download or print this page. Return completed form to:
Writers Block Ink
300 - 302 State Street, New London, CT 06320.

Questions? contact us: writersblockink@comcast.net; 860.44.BLOCK

Some scholarships are available for Summer on the Block. Please note that:
- Recipients must be 21 or under and residents of New London County.
- Scholarship applications must be received with the camp application.
- Full or partial scholarships are awarded based on need and availability.
- Scholarship Donors may specify preference or eligibility for scholarships.
- All Scholarship applicants must complete fundraising activities (program ad sales; t-shirt sales; dvd sales) to defray costs and supplement scholarships

Instructions
Carefully follow the procedure detailed in the registration packet. Complete the registration form as well as this scholarship request form. Use separate forms for each student. Return by June 16, 2007 to: 300 - 302 State Street, New London, CT 06320. Questions: writersblockink@comcast.net; 860.44.BLOCK.

Student: please include a description of your writing and/or performance experience and what you hope to learn and contribute to the Summer on the Block Camp. If you have attended in the past, please mention how The Writer’s Block has affected your writing/performing, and why you'd like to return (approx. 300 Words). Use back of form if necessary.

Summer on the Block Camp Scholarship Application

Name of Student:
Name of Parent /Guardian:
Home Address:
City, State, Zip:
Phone (Day) and (Evening):
Date of Birth: (MM/DD/YY)
Grade Completed (6/07)
Student e-mail:
Emergency Contact:
Emergency Contact Phone:
Areas of Interest: (Circle only 2)
Playwriting - Acting - Dance - Singing - Music - Set Design and Construction

Household gross income in 2006 (Check One):
Please provide a copy of your family’s most recent tax return form 1040.

Less than $30,000 $40,000 - $50,000 $60,000 - $75,000
$30,000 - $40,000 $50,000 - $60,000

# of Children in Family:

Any other factors you would like us to consider:

By signing below, I affirm that the information I have provided is true and correct.

Signature:
Date:

Please complete form and return to:
Writers Block Ink
313 State Street, New London, CT 06320.

Questions? contact us: writersblockink@comcast.net; 860.44.BLOCK

CLICK HERE TO DOWNLOAD SCHOLARSHIP FORM