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Registration Form

Please complete and submit the following application form. Please print CLEARLY These details will not be disclosed to anyone outside C31 and SYN without the applicant’s permission. YOUR DETAILS Name Date of birth ______/_______/______ Cultural background Languages spoken other than English Address (with postcode) Home phone number Mobile phone number Email address Any dietary and/or religious requirements? EMERGENCY DETAILS (please get a guardian/parent to fill out if under 18): Name of emergency contact person Relationship to applicant Emergency contact phone number Do you / your child have any allergies or taking any medication (give details) Medicare Number

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Interest and Experience:

1- In a few sentences, tell us a bit about yourself, what you do, what you like and what you’re passionate about?

2- Why are you interested in taking part in Working Title?

3- What are some of the issues that concern you as a young person in a multicultural society?

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4- If you were selected to be part of the project, tell us about two ideas that you would present for a 5 mins long documentary film?

5- Tell us a bit about your experience in filmmaking? And the specific area of filmmaking that interests you most: camera, sound, editing, writing or directing?

6- Do you think you can commit yourself to 4 to 6 hours a week for ten weeks and to see the project through?

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PHOTOGRAPHY CONSENT FORM: tH Do you give permission for C31 or SYN to take photographs or video footage of you during the project? The photographs and footage will be used to promote similar projects for young people. If you would prefer not to be photographed or filmed that is okay just let us know on this form so we do not in include you in the photographs or video footage. I do / do not (please circle) wish to be photographed by C31 and SYN. I do / do not (please circle) wish to be filmed by C31 and SYN.

APPLICANT CONSENT (IF OVER 18 YEARS OF AGE) Applicant Signature (if over 18 – if under please get your parents to fill out the details below) _________________________________________ (sign) Applicant Name _________________________________________ (print name) PARENT CONSENT (IF UNDER 18 YEARS OF AGE) As a parent or guardian, I give permission for my child to attend the above activity: Parent/ Guardian Name _________________________________________ (print name) Parent’s/Guardian’s Signature _________________________________________ (sign)

PLEASE EMAIL OR POST THIS TO C31 by Friday July 8th 2011 ADDRESS: Vessal Safaei Level 1, 501 Swanston street, Melbourne, VIC, 3000. Or EMAIL: vessalsafaei@c31.org.au If you have any questions or would like more information, please contact Vessal Safaei, Project Coordinator at (03) 96 603 131 or email vessalsafaei@c31.org.au www.c31.org.au/workingtitle

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/Working-Title-Registration-Form  

http://msn.c31.org.au/workingtitle/Working-Title-Registration-Form.doc

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