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2011-2012 Slam Registration

Participant Information

All fields marked with an * are required. Please complete entire form.
Participant Name *

First
Last
Address *

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Email Address *
Retype Email Address *
Phone Number *

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Date of Birth *
MM/DD/YYYY
School *
If graduated, but not attending college, type "N/A"
Current GPA *
Use GPA from last term if current grades not available. Minimum 2.7 GPA is required to participate in the slam.

Parent / Guardian information

For participants under the age of 18
Name *

First
Last
Phone *

###		 -
###		 -
####
Relationship *
 Parent 
 Legal Guardian 
 Other 
If other, please explain:

Participant Agreement

I confirm that the above information is true and correct, and that I have reviewed all of the participant rules and requirements to participate in the 2011-2012 PYPM Slam Season. If selected for the 2012 Philly Youth Slam Team, I agree to provide verification of my GPA, age and residency, as well as parental consent to travel with the Philly Youth Poetry Movement to the Brave New Voices Youth Poetry Slam Festival.
Check box to confirm *
 I agree with the above statement