PIOP Group Registration

To register & pay the $312 group registration fee (8 students) for the Putting it on Paper Workshop, September 10, 2016 at Mt. Hebron Missionary Baptist Church located at 1233 State Highway 66; Garland, TX 75040, complete the registration form below:

Name of Organization: *
Organization's Representative: *
Address: *
E-mail: *
Phone Number: *
Contact Person's Name: *

Each organization may register up to 40 students grades 6-12 only. Please provide the names, grade and gender of each participant attending in the spaces below. If your overall number drops, please let us know immediately so other youth can fill the available spaces.


Participants Information

1. Student's Name: *
1. Select Grade: *
1. Select Gender: *

2. Student's Name: *
2. Select Grade: *
2. Select Gender: *

3. Student's Name: *
3. Select Grade: *
3. Select Gender: *

4. Student's Name: *
4. Select Grade: *
4. Select Gender: *

5. Student's Name: *
5. Select Grade: *
5. Select Gender: *

6. Student's Name: *
6. Select Grade: *
6. Select Gender: *

7. Student's Name: *
7. Select Grade: *
7. Select Gender: *

8. Student's Name: *
8. Select Grade: *
8. Select Gender: *

How did you hear about the workshop?: *

By submitting pre-registration, you agree to the following terms and conditions:
Release of Liability: I hereby give permission to the above child (rens) to participate in Teen Graffiti’s “Puttin' It On Paper" Writing Seminar sponsored by Teen Graffiti Magazine, Teens Reaching Teens, Incorporated and Writer's Educational Services I hereby irrevocably and unconditionally release, discharge, and waive any and all claims or causes of action of any nature now or hereafter existing, whether known or unknown, against Teen Graffiti Magazine, Teens Reaching Teens, Incorporated and Writer's Educational Services, their agents, employees, officers, or representatives from any and all responsibility for any injuries or damage sustained by me my child or family, arising from any act or omission, negligent or otherwise, of Teen Graffiti Magazine, Teens Reaching Teens, Incorporated and Writer's Educational Services, their agents, employees, officers, or representatives in connection with Teen Graffiti’s “Puttin' It On Paper".

Medical Waiver: In the event of an emergency, I DO grant permission to Teen Graffiti Magazine, Teens Reaching Teens, Incorporated and Writer's Educational Services to transport my child/ward to a hospital/after hours clinic for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. As the parent/legal guardian, I give full authorization to Teen Graffiti Magazine, Teens Reaching Teens, Incorporated and Writer's Educational Services and its employees, agents and/or subcontractors to secure medical care or treatment for above named youth(s). This treatment may include assistance from the nearest physician, medical clinic, hospital, trained nurse or EMT in the event of illness or injury that requires immediate attention, as determined by the event staff. In the event that I cannot be contacted, and an emergency has occurred, I give permission to the treating medical institution and/or medical providers to hospitalize and administer the appropriate treatment deemed medically necessary. I further agree that Teen Graffiti Magazine, Teens Reaching Teens, Incorporated and Writer's Educational Services and its employees and agents will not be held responsible for injuries or damages arising from the provision of any such emergency medical treatment. I understand that as a parent/legal guardian, I will be responsible for the cost of any service or treatment provided. This authorization shall remain effective until he/she completes their activities in this program. I have read this document, I understand its contents, and I agree to its terms.

Publication Consent: This form is used to obtain permission for Teen Graffiti Magazine, Teens Reaching Teens, Incorporated and Writer's Educational Services to use volunteers, students and parents or any other participants attending Teen Graffiti’s “Puttin' It On Paper” Writing Seminar artwork, photographs, website and/or statements in publications, media releases and/or information display.

Organization's Representative registering Group: *
Today's Date: *
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