CSC | Community ACT Institute Registration | Spring 2023

Join us from 4pm-6pm, March 13th-24th Monday through Friday, for our ACT Institute. Participants ages 13-18 engage in activities and exercises focused on an increased understanding of themselves and their world.

We explore complex and necessary topics such as: culture, influence/bias, stress, place, identity, oppression, conflict management, and art activation. All while earning a stipend up to $225!

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* 1. Youth Participant Information

First and Last Name *

School *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Age *

Email Address *

Phone Number *

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* 2. How did you hear about ACT?

Social Media

From a friend

A CSC member

Flier/Poster

Other (please specify)

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* 3. Participants will need to commit to attending the workshops for the full duration. 100% completion and attendance of the workshop is required to receive a full stipend. In order to receive a partial stipend, you must attend at least 80% of the workshops. Will you be able to commit to the dates and times of this workshop? If not please list your conflicts below.

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* 4. How do you identify racially? (Please choose all that apply)

Asian / South Asian / Pacific Island Descent

Black / African Descent

Latina/o/e/x Descent

Middle Eastern Descent

Multiracial / Biracial

Native / Indigenous Descent

White / European Descent

Unsure

Prefer not to answer

Self-Identify / Additional Comments

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* 5. How do you identify ethnically? Please self-identify. (Non-Exhaustive Examples: African American, Anglo, Chicano/Chicana, French, Mixed Ethnicity, Mixed European Decent, Puerto Rican, Yoruba, etc)

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* 6. What's your national origin? (Please name the country where you were born or share additional comments)

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* 7. What is your gender identity? (Please choose all that apply)

Transgender

Cisgender

Queer

Woman

Man

Two-Spirit

Non-Binary or Gender Non-Conforming

Genderqueer or Genderfluid

Agender

Questioning or Unsure

Prefer not to answer

Self Identify / Additional Comments

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* 8. What are your pronouns? (Please choose all that apply)

She/Her

They/Them

He/Him

Xe/Xem

Questioning or Unsure

Prefer not to answer

Self Identify / Additional Comments

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* 9. What is your sexual orientation? (Please choose all that apply)

Queer

Pansexual

Lesbian

Gay

Heterosexual

Bisexual

Asexual

Questioning or Unsure

Prefer not to answer

Self Identify / Additional Comments

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* 10. What is your first language?

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* 11. What is your (family) class position?

Low Income/Poor

Working Class

Middle Class

Upper Class

Owning Class

Self Identify / Additional Comments

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* 12. How do you identify related to ability and access? We recognize the terms below are not a complete reflection of the diversity in experience of ability and accessibility. Nor does it capture the variation in needs for accommodations if you do not see an identifier that represents you, please self identify in the area provided.

Neuro-diverse

Living with a disability

Living without a disability

Self Identify / Additional Comments

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* 13. What is your Religious/Spiritual Affiliation?

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* 14. Art

What is one thing you would like to gain from this workshop?

What specific art form(s) would you like to explore in this workshop? (Examples: painting, theatre, hip-hop dance, drawing, watercolor, guitar, etc)

Are you interested in music (production, creation, recording, etc)?

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* 15. Passion

Who is an artist you admire and why?

What is a social issue you feel passionately about?

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* 1. Youth Participant Information

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* 2. How did you hear about ACT?

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* 4. How do you identify racially? (Please choose all that apply)

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* 5. How do you identify ethnically? Please self-identify. (Non-Exhaustive Examples: African American, Anglo, Chicano/Chicana, French, Mixed Ethnicity, Mixed European Decent, Puerto Rican, Yoruba, etc)

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* 6. What's your national origin? (Please name the country where you were born or share additional comments)

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* 7. What is your gender identity? (Please choose all that apply)

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* 8. What are your pronouns? (Please choose all that apply)

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* 9. What is your sexual orientation? (Please choose all that apply)

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* 10. What is your first language?

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* 11. What is your (family) class position?

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* 13. What is your Religious/Spiritual Affiliation?

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* 14. Art

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* 15. Passion

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* 16. Is there anything else that you would like us to know (questions, comments, or concerns)?