Mic’d Up Podcast sessions

Mic’d Up Podcast sessions

The program application must be completed by a parent/guardian.
STUDENT INFORMATION
Got something to say? Mic’d Up is your space to speak, share, and explore! Teens can book their own sessions and bring friends along to discuss any topic they’re passionate about — from music and sports to school life, social issues, or the latest trends. Each session gives participants the chance to voice their opinions, listen to others, and even record their thoughts for a real teen podcast. It’s a fun, creative, and safe space where you get to be heard and connect with others on your own terms.
Student Name*

First NameLast Name
Student Date of Birth*

MonthDayYear
Student Email*
example@example.com
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Gender*

FemaleMaleOther
School Name*
Grade*
Student Ethnic Origin*

American Indian/Alaska NativeAsianBlack/African AmericanNative Hawaiian/Pacific IslanderWhiteTwo or More RacesPrefer not to say
Please note: Y-USA requests the above information from YMCA participants throughout the nation for program funding and demographic purposes.
PODCAST INFORMATION
Which subjects are you interested in talking about?*
Do you want to bring friends?*

YesNo
How many guests will join your session?*
Podcast sessions take place on Wednesdays from 6:00–7:00 PM. Which date(s) would you like to sign up for? Max 3

January 8thJanuary 15thJanuary 22ndJanuary 29th
February 4thFebruary 11thFebruary 18thFebruary 25thMarch 4th
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name*

First NameLast Name
Relationship to Student*
Parent/Guardian Date of Birth*

MonthDayYear
Parent/Guardian Phone Number*
Parent/Guardian Email*
example@example.com
Address (If different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMERGENCY CONTACT INFORMATION
Do you want to provide Emergency Contact information for the student that is different from the Parent/Guardian information provided above?*
Name

First NameLast Name
Relationship to Student
Phone Number
Address (If different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Code of Conduct Agreement*
Waiver & Release of Liability*
Please confirm you are not a robot*
Student Signature

Clear
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: