BLMT Parent Registration for Student Participation Form

Parent / Guardian Information

First Name

Last Name

Phone/Mobile

Preferred Method of Contact

Phone

Text Message

Address

City

State

Student Information

Student First Name

Student Last Name

Student Age

Grade Level

School

Showcase Participation

What would your child like to showcase?

Performance Details

Brief Description of Talent / Activity

Estimated Participation Length

Equipment Needs

Microphone

Music/Sound System

Open stage space

Not sure yet

Why would participation in this showcase be meaningful for your child?

Permissions

Photo / Video Permission

I understand photos and videos may be taken during the event for promotional and community purposes.

I understand participation is subject to scheduling, space availability, and event coordination.

Participation & Liability Acknowledgment

Checkbox Field

I understand that participation in the Black Learners Matter Too™ Community Market is voluntary. On behalf of myself and the participating student(s), I acknowledge and accept responsibility for participation in event activities and understand that Quarantine Racism Educational Services, the City of Burlington, its departments, officials, employees, agents, volunteers, representatives, sponsors, affiliates, and event partners shall not be held liable for injuries, damages, losses, accidents, theft, or other incidents arising from participation in the event except as otherwise required by law. I further understand that parents/guardians are responsible for supervising and monitoring their participating child before, during, and after event activities unless otherwise specifically arranged through an approved organization or program. By submitting this form, I acknowledge and agree to these participation terms.

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Give Your Child an Opportunity to Shine

Parent Registration Form

Parent / Guardian Information

Student Information

Showcase Participation

Performance Details

Permissions

Participation & Liability Acknowledgment

For Families

For Educators & Administrators

Community Impact

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