Student First & Last Name *

First Name

Last Name

Birthday

MM

DD

YYYY

What's your phone number? *

(###)

###

####

Parent/Guardian Consent *

I have obtained permission from my parent or guardian to partake in this program.

Phone number of parent or guardian *

(###)

###

####

What are your pronouns? *

She/Her

He/Him

They/Them

Other

Have you or your family ever experienced any of the following: Gender based violence, Racial discrimination, Incarceration, Foster care, Undocumented or citizenship status in transition, Workplace discrimination, Microaggressions, Homelessness *

Yes

No

Maybe/Not Sure

Chose not to answer

Have you or your family ever experienced any of the following: a sensory impairment (vision or hearing), a mobility impairment, a learning disability (e.g. ADHD, dyslexia), a mental health disorder, a disability or impairment not listed here?

Yes

No

Maybe/Not Sure

Chose not to answer

Do you qualify to get free or reduced lunch? *

Yes

No

Maybe/Not sure

I choose not to answer

I often think about who creates the media I watch and what motivates them to create it. *

Strongly disagree

Disagree

Not sure

Agree

Strongly agree

In general, I think representation of my community is accurate in the media (TV, film, podcasts, etc.) *

Strongly disagree

Disagree

Not sure

Agree

Strongly agree

In general, I think representation of women and girls is accurate in the media (TV, film, podcasts, etc.) *

Strongly disagree

Disagree

Not sure

Agree

Strongly agree

I am familiar with the concept of gender equality. *

Not familiar at all

Not very familiar

Somewhat familiar

Very familiar

Extremely familiar

I am familiar with the concept of advocacy *

Not familiar at all

Not very familiar

Somewhat familiar

Very familiar

Extremely familiar

How comfortable are you speaking publicly (for example, giving a speech)? *

Not comfortable at all

Not very comfortable

Somewhat comfortable

Very comfortable

Extremely comfortable

I’ve never done it before

How comfortable are you approaching people you don’t know and engage with them in conversation? *

Not comfortable at all

Not very comfortable

Somewhat comfortable

Very comfortable

Extremely comfortable

I’ve never done it before

How comfortable are you telling a story from beginning, to middle, to end? *

Not comfortable at all

Not very comfortable

Somewhat comfortable

Very comfortable

Extremely comfortable

I’ve never done it before

How comfortable are you providing feedback to your peers? *

Not comfortable at all

Not very comfortable

Somewhat comfortable

Very comfortable

Extremely comfortable

I’ve never done it before

How comfortable are you handling conflict? *

Not comfortable at all

Not very comfortable

Somewhat comfortable

Very comfortable

Extremely comfortable

I’ve never done it before

How many times have you engaged in: activism? *

I have not participated

I have participated in activism 1-4 times

I have participated in activism 5 or more times

I believe that I’m the first to speak in a group setting. *

Yes

No

Sometimes

Not Sure

I believe that I’m often more quiet in a group setting *

Yes

No

Sometimes

Not Sure

How would you describe your learning style: *

Visual learner: I need to read along when I hear a story or while in class. I learn best with pictures and videos. B. kinesthetic learner: I learn best while doing something interactive, like a game or science experiment.

Auditory learner: I’m really good at remembering songs. I like to read out loud or hear it read by others, it’s how I recall books best.

Kinesthetic learner: I am really good at absorbing information best through touch, movement and motion.

More than one above.

I’m not sure

I am interested in being part of the film, TV, news or entertainment industry. *

Yes

No

Maybe

Have you made a film before? *

Yes

No

Yes, but I don’t want to share it with anyone

Are you interested in receiving information about additional enrichment opportunities? *

Yes

No

Maybe

Not sure yet

Program Stipend

I understand that Justice for My Sister will provide me with a $100 stipend upon completion of the program. My attendance to 6 of the 8 sessions and completion of the post-survey are required to obtain this stipend.