Student First & Last Name
*
First Name
Last Name
Age
*
Birthday
MM
DD
YYYY
What's your email?
*
What's your phone number?
*
(###)
###
####
Parent/Guardian Consent
*
I have obtained permission from my parent or guardian to partake in this program.
Name of parent or guardian who will sign participation agreement on your behalf
*
Phone number of parent or guardian
*
(###)
###
####
Email of parent or guardian
What neighborhood do you reside in?
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Sylmar
Pacoima
San Fernando
Other. Please expand below
If you answered other, please tell us what neighborhood do you reside in:
What school do you attend?
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
If other, please specify
What is your gender?
*
Female
Male
Nonbinary
Transgender
Other
If other, please specify
What are your pronouns?
*
She/Her
He/Him
They/Them
Other
If other, please specify
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?
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Yes
No
Maybe/Not sure
I choose not to answer
Can you explain what media literacy is?
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I often think about who creates the media I watch and what motivates them to create it.
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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.)
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Strongly disagree
Disagree
Not sure
Agree
Strongly agree
Why do you agree or disagree that representation of your community is accurate in the media (TV, film, podcasts, etc.)?
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In general, I think representation of women and girls is accurate in the media (TV, film, podcasts, etc.)
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Strongly disagree
Disagree
Not sure
Agree
Strongly agree
Why do you agree or disagree that representation of women and girls is accurate in the media (TV, film, podcasts, etc.)?
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I am familiar with the concept of gender equality.
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Not familiar at all
Not very familiar
Somewhat familiar
Very familiar
Extremely familiar
I am familiar with the concept of advocacy
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Not familiar at all
Not very familiar
Somewhat familiar
Very familiar
Extremely familiar
How comfortable are you speaking publicly (for example, giving a speech)?
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Not comfortable at all
Not very comfortable
Somewhat comfortable
Very comfortable
Extremely comfortable
I’ve never done it before
How confortable are you approaching people you don’t know and engage with them in conversation?
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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?
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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?
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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?
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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?
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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.
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Yes
No
Sometimes
Not Sure
I believe that I’m often more quiet in a group setting
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Yes
No
Sometimes
Not Sure
How would you describe your learning style:
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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.
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Yes
No
Maybe
What is your main creative outlet?
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Have you made a film before?
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Yes
No
Yes, but I don’t want to share it with anyone
What is your favorite TV show, film, podcast, and/or YouTube account?
*
What is one goal you have for participating in this filmmaking intensive?
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Are you interested in receiving information about additional enrichment opportunities?
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Yes
No
Maybe
Not sure yet
How did you hear about this workshop series?
*
Website
Friend
Justice4Sister Instagram
Justice4Sister Twitter
Justice for My Sister Facebook
Other account social media,
Other organization
Other
If other, please specify
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.