First Name *

Last Name *

Preferred Name

Pronouns

Age

Grade

Other School

School Alliance at Benson High School Alliance at Meek High School Beaumont Middle School Benson High School Cedar Park Middle School Camas High School Centennial High School Clackamas High School Cleveland High School David Douglas High School Franklin High School Grant High School Gresham High School Happy Valley Middle School Jefferson High School La Center High School, WA Lincoln High School Leodis McDaniel High School Metro Learning Center (MLC) Oregon City Public Schools Parkrose High School Portland Public Schools Reynolds High School Roosevelt High School Sunnyside Environmental School Ida B. Wells High School Sam Barlow High School Springwater Trail High School Other

Which race or ethnicity best describes you?

Email

Phone 1

Address Line 1

Address Line 2

City

State/Province Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

Zip/Postal Code

Country United States of America Canada Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia (Plurinational State of) Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo (the Democratic Republic of the) Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czechia Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands [Malvinas] Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea (the Democratic People's Republic of) Korea (the Republic of) Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia (Federated States of) Moldova (the Republic of) Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Sweden Switzerland Syrian Arab Republic Taiwan (Province of China) Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Türkiye Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom of Great Britain and Northern Ireland United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Western Sahara* Yemen Zambia Zimbabwe

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Email

Parent/Guardian Cell #

Parent/Guardian Alternate #

We aim to create a safe, welcoming environment for all participants. Please read our group agreements: Stay engaged. Speak your truth kindly and responsibly. Refrain from negative talk about yourself and others. Be open to new ideas. Please also read our ground rules for being in the Bodecker building: No smoking or vaping. Participants must stay in the building throughout the workshop. Respect the space and each other. Have you read and do you agree to all of the above?

Photo / Video Release

Please note that Bodecker retains the right to responsibly share work created in a Bodecker program for promotional and/or educational purposes (music, visual art, writing).

Parent Permission

Health Care Provider *

Health Care Provider Phone Number *

Health Concerns (including but not limited to: special health issues, activity limitations, allergies, or medications):

Do you have any dietary restrictions? If so, please list them here.

Click here if you'd like to receive our Statement of Health Care Policies

Why do you want to be a part of this workshop?

What are you interested in?

We understand that plans change, but we also believe that dreams matter. Where do you see yourself in five years?

Please upload an example of your art, whether it's music, visual, or writing.