Queer Utopia: Creativity and Expression Lab Registration Form

Queer Utopia: Creative Lab Registration Form
Affirmations' Queer Utopia: Art and Expression Lab is an 8-week program designed to empower LGBTQ+ middle schoolers (ages 11–14) by building self-esteem, fostering connections, and using self-expression as a tool for coping and resilience.

Running weekly from early February through March, the program offers a safe and welcoming space for participants to explore identity, creativity, and community. Each Thursday from 5:30–7:30 PM, sessions will include engaging activities that encourage collaboration, personal reflection, and leadership, culminating in a celebratory art gallery to showcase their work. No prior art experience is required—just bring your imagination!

While this is not a therapy group, the program takes a therapeutic approach and will include pre- and post- surveys to evaluate intended outcomes.

Due to limited spots, submission of this form does not guarantee acceptance into the workshops. You may be placed on a waitlist if we exceed capacity for each workshop. Priority will be given to those who register before the workshop start.

Registration will close on January 26th.

Location: Affirmations - 290 W. 9 Mile Rd. Ferndale, MI 48220

Who: LGBTQ+ Middle Schoolers (11-14)

When: Thursdays at 5:30pm - 7:30pm (February 5 - March 26)

Cost: $120 ($15 per session) - to be collected once your spot is confirmed
To ensure there are no barriers to access we are offering need-based partial and full scholarships.
- Partial Scholarships: $60 ($7.50 per session)
- Full Scholarships: $0
Questions? Email Joe at jvolpe@goaffirmations.org

Applicant Information
Name*

First NameLast Name
Legal Name (if different from the previous name)

First NameLast Name
Pronouns:*
Example: She/They
Date of Birth*

MonthDayYear
Age on February 5th, 2025*
Must be in or eligible to attend MIDDLE SCHOOL and between the ages of 11-14 as of 2/5/2025.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant Email*
example@example.com
Primary Phone*
Please enter a valid phone number.

Parent/Guardian Information

If you are under 18, Parent/Guardian Information is required.
Parent/Guardian Name

First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.
Parent/Guardian Email
example@example.com
Emergency Contact Information

Emergency Contact must be 18+.
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Relation*
Is this person affirming of your sexuality / gender identities?*
What name does this person know you by?*

Experience / Interest Areas
What do you like about art?*
.
Are there areas of interest that you want to explore in this program?*

Scholarship Information
Cost: $120 ($15 per session) - to be collected once your spot is confirmed

To ensure there are no barriers to access we are offering need-based partial and full scholarships.
- Partial Scholarships: $60 ($7.5 per session)
- Full Scholarships: $0
Would you like to apply for a needs-based scholarship?*
If you selected yes for the previous question, what type of scholarship are you requesting?

Parent/Guardian Consent
1. Permission to Participate
I, the undersigned, hereby give my permission for my child, as named above, to participate in the Queer Utopia: Creativity & Expression Lab at Affirmations Community Center, including all activities related to the program.

2. Medical Treatment Consent
In the event of an emergency or medical situation, I authorize Affirmations Community Center staff and its representatives to seek emergency medical treatment for my child, if necessary. I understand that I will be notified as soon as possible in the event of an emergency.

3. Waiver and Release of Liability
I, the undersigned, agree to release and hold harmless Affirmations Community Center, its staff, volunteers, and agents from any and all claims, damages, or liabilities arising out of or in connection with my child's participation in the program. This includes any injury or illness sustained during the program, except where such injury or illness is caused by the gross negligence or willful misconduct of the community center.

4. Behavioral Expectations
I acknowledge that my child is expected to follow the rules and guidelines set forth by the Affirmations Community Center during the program. I understand that failure to adhere to these rules may result in my child being removed from the program.

6. Acknowledgment of Risk
I acknowledge that participation in the program may involve certain inherent risks, including but not limited to physical activity and interaction with other children. I assume full responsibility for my child's actions, health, and safety while participating in the program.
Parent/Guardian Name

First NameLast Name
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Queer Utopia: Creative Lab Registration Form

Applicant Information

Parent/Guardian Information

Emergency Contact Information

Demographic Information

Experience / Interest Areas

Scholarship Information

Parent/Guardian Consent