Participant First & Last Name *

First Name

Last Name

When is your birthday?

MM

DD

YYYY

What's your phone number? *

(###)

###

####

What is your race/ethnicity? *

African-American/Black

Latino/Latinx/Mestizx

Asian/Pacific Islander

Caucasian/White

Native American/Indigenous

Middle Eastern/Arab

Bi-racial/Multiracial

Other

What is your gender? *

Cis woman

Cis man

Nonbinary

Transgender

Two-Spirit

Other

Are you currently experiencing homelessness? [This could also mean couch surfing, staying with someone temporarily, or sleeping in a place that is not safe or meant for human habitation]

Yes

No

Have you or your family ever experienced any of the following? Check all that apply.

Gender based violence

Racial discrimination

Incarceration

Foster care

Undocumented or citizenship status in transition

Workplace discrimination

Microaggressions

Homelessness

None of the above

Other

Choose not to answer

Are you a Veteran or have you served in the Military?

Yes

No

Not sure

Have you ever experienced any of the following? Check all that apply.

A sensory impairment (vision or hearing)

A mobility impairment

A learning disability (e.g. ADHD, dyslexia)

A mental health disorder

I have an impairment, disorder, or disability that I chose not to specify

None of the above

Other (please specify below)

According to Covered California income guidelines and salary restrictions, if an individual makes less than $47,520 per year or if a family of four earns wages less than $97,200 per year, then they qualify for government assistance based on their income. Is your family low-income?

Yes

No

Choose not to answer

If selected, I commit to attend all sessions that PA Certification Training Program convenes at the times and dates described in this application form: *

Dates for the program may be found on the description of the application form.

Yes

No

Maybe

How you do describe your experience in the film, TV, news or entertainment industry? *

Novice/Beginner - I have not made a film or written a script.

Student - I have written a script and/or made a film that’s been publicly exhibited.

Entry-level - I have some experience on professional film sets as a PA or assistant.

Freelancer - I have a specific trade that I live off of (production, DP, sound) but I haven’t written a script.

Mid-career Writer/director - I have written and directed films that have been broadcast and/or won awards.

Industry professional who has 5+ years experience.

Other.

Do you have experience working in any areas of production for Film and Television? *

Yes

No

I would say I have excellent time management skills *

Yes

No

How did you hear about this workshop series? *

Friend

Previous fellow

Website

Justice4Sister Instagram

Justice4Sister Twitter

Justice for My Sister Facebook

Other social media account

Other organization

Los Angeles Department of Cultural Affairs

Other

What additional aspirations do you have in film/television? [Mark all that apply] *

Directing

Producing

Writing

Cinematography/Camera Dept.

Production Design/Art Dept.

Editing

Sound

Marketing

Acting

Other

Program Cost: The value of the 8-week certification series is $775, however this year we are providing partial scholarships to all participants, along with job placement for those who reside in Los Angeles. Total cost of the program with the partial scholarship is $300. *

I understand that, if chosen to partake in the PA Certification Program, the services will be offered at a discounted rate, and I agree to pay my registration fee of $300 by June 20 at 11:59pm.

I understand that there are a limited number of payment plans available to those unable to pay the $300 all at once. I'm in a financial situation that currently limits my ability to pay the flat $300 fee and instead request to pay $170 by June 20 at 11:59pm and $170 by July 18 at 11:59pm. I understand that JFMS values self-accountability, and commit to doing my part to follow-through on my business agreement to the organization.

I am currently in a financial situation that prohibits me from paying anything to partake in this professional development and job placement program. I understand that there are extremely limited full scholarships this year, and only about 10% of participants will be able to be awarded a full scholarship. Without a full scholarship, I could not participate in this program. With a full scholarship, I commit myself to be punctual, participatory, and make full use of this life-changing opportunity.

Terms and conditions *

To participate in the program you need to agree with our terms and conditions

I understand that Justice for My Sister is working with a panel of readers to review applications, and there is a chance I might not be selected, due to limited capacity.

I agree that all the information I have provided is transparent, representative and true. I have voluntarily submitted my own original material to Justice for My Sister for the sole purpose of review for acceptance to the PA Certification Program.

I agree to complete the post survey provided by JFMS staff upon completion of the program.

I consent to full communication regarding my progress within the program with Justice for My Sister funders, including but not limited to: my demographic information, justice system involvement, service assessments, services information, and my program outcomes on a need-to-know basis.