HOME
ABOUT US
PROGRAMS
Join The Family
Back
Who we are
History
Staff
Community Partners
Back
How We Roll
Programs
HOME
ABOUT US
Who we are
History
Staff
Community Partners
PROGRAMS
How We Roll
Programs
Changing lives through the arts in Springfield, Ohio.
Join The Family
Participant Form
Please complete the form below
Name of person filling out this form
*
First Name
Last Name
Child Info
Child's Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Pronouns
*
she/her/hers
he/him/his
they/them/theirs
she/they
he/they
Which of the following best describes the child?
Asian or Pacific Islander
Black or African American
Hispanic or Latino
Native American or Alaskan Native
White or Caucasian
Biracial or multiracial
A race/ethnicity not listed here
Prefer not to answer
School and Grade
*
Interested Art Forms
Mark all that apply
Drawing/Painting
Sculpture/Ceramics
Photography
Fabric/woven art
Dance
Theatre
Music
Writing
Other
Why is this person interested in joining Project Jericho?
Parent/Guardian Info
Parent/Guardian Name
*
First Name
Last Name
Relationship to child
*
Date of Birth
*
MM
DD
YYYY
Preferred Contact Method
What is the parent/guardian's preferred contact method?
Phone Call
Text Message
Email
Parent/Guardian Name
First Name
Last Name
Relationship to child
Date of Birth
MM
DD
YYYY
Family Info
Family Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Family Phone Number
*
(###)
###
####
Family Email
*
How did you hear about Project Jericho?
*
Mark all that apply
Friend
School
Caseworker
Probation Officer
Website
If you were referred by an organization, complete the following.
Reference Name
First Name
Last Name
Reference Phone Number
(###)
###
####
Reference Organization
Reference Email
Date of submission
*
MM
DD
YYYY
Thank you!
