Name *

First Name

Last Name

Phone

(###)

###

####

Is your family low income, underserved, kinship, or fostering? *

Check all that apply

Low Income

Underserved

Kinship

Fostering

If you chose low income, please indicate if you use any of the following:

Check all that apply

EBT

SNAP

Free or Reduced Lunch

Medicaid

Rental Assistance

Other

Would your family be interested in any of the following resources at Cinematique 2025?

Click all that apply

Dental Cleanings

Health Screenings

Sports Physicals

Vision Exams

Blood pressure checks

Mental Health screenings

Are members of your family:

FLU Vaccinated

COVID Vaccinated

Does everyone in your family know how to swim?

Yes

No

Please Confirm *

I understand that by filling this form I am confirming my participation should I be confirmed for the event.

Please Confirm *

I acknowledge that the completion of this form is not the same as being confirmed for the event

Please Confirm *

I understand that if I complete this form and then do not attend, this can adversely affect my ability to receive complimentary tickets in the future

Do you accept the following agreement *

Yes

No