Multimedia Bootcamp Registration Form

Multimedia Bootcamp Registration Form

1) PARTICIPANT’S PERSONAL DETAILS

Name *

First

Last

Other Names

Gender *

Male
Female
Other

Place of Residence

Mobile No: *

Email *

Age *

Nationality *

2) EDUCATION BACKGROUND

CURRENT SCHOOL *

GRADE LEVEL *

CLUBS/ ACTIVITIES *

3) PARENT / GUARDIAN DETAILS

Name *

First

Last

Phone *

Email *

Relationship to the Participant: *

4) MULTIMEDIA INTERESTS

Briefly describe the participant’s interest in multimedia (e.g., photography, video editing, graphic design etc.): *

5) EXPECTATIONS

What does the participant hope to gain from the Multimedia Bootcamp? *

6) EMERGENCY CONTACT

In case of emergency, who should be contacted?

Name *

First

Last

Phone *

Relationship *

7) CONSENT AND AGREEMENT

By submitting this application, I, the undersigned guardian, confirm that the information provided is accurate to the best of my knowledge. I understand that participation in the Multimedia Bootcamp is subject to availability, and I consent to my child’s involvement in the program.

Guardian’s Signature: *

Date *

8) PAYMENT DETAILS

Mpesa Paybill: 836036
Account Number: Child’s First and Last Name

To pay through bank

Account Name: Africa Digital Media Institute
Bank: NCBA Bank
Branch: Harambee Avenue
Account Number: 2665570197
Bank Branch Code: 110
Swift Code: CBAFKENX

Please share the Mpesa confirmation message or bank receipt on 0706 349 696