Name *

First Name

Last Name

Phone *

(###)

###

####

Race / Ethnicity *

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

Hispanic or Latino or Spanish Origin

White

Other

Is your family *

Please select all that apply

Fostering

Kinship

Low income

Underserved

Other

Will all of your family members be attending Cinematique 2025 *

Yes

No

Which Cinematique Collaborating Partner referred your family *

Casey Family Programs

The YMCA of Greater Seattle

Big Brothers Big Sisters of Puget Sound

Community Passageways

Treehouse

The Girl Scouts of Western Washington

Byrd Barr Place

Boys and Girls Club of Bellevue

Other

None

Do you have an EBT Card *

Yes

No

Does your family qualify for SNAP Supplemental Nutrition Assistance Program *

Yes

No

Are all adults in your family registered to vote *

Yes

No

If provided at Cinematique would your family sign up to have a dental cleaning at the event *

Yes

No

Maybe

If provided at Cinematique would your family sign up to have a sports physical at the event *

Yes

No

Maybe

If provided at Cinematique would your family sign up to have a vision exam at the event *

Yes

No

Maybe

If provided at Cinematique would your family sign up to have a blood pressure check at the event *

Yes

No

Maybe

If provided at Cinematique would your family sign up to have a mental health screening at the event *

Yes

No

Maybe

If provided at Cinematique would anyone in your family be interested in receiving a COVID vaccination *

Yes

No

Maybe

If provided at Cinematique would anyone in your family be interested in receiving a FLU vaccination *

Yes

No

Maybe

If offered at Cinematique would your family be interested in a complimentary membership at the YMCA of Greater Seattle *

Yes

No

Maybe

If offered at Cinematique would your family be interested in registering for complimentary passes to University of Washington for various sporting events throughout the year *

Yes

No

Maybe

Does everyone in your family know how to swim *

Yes

No

Is your family registered for Amazon Access which gives you 50% discount on Amazon Prime and allows you to use your EBT card for home delivery of eligible items include fresh fruits and vegetables *

Yes

No

Maybe

Do you agree to the Cinematique Participation and Release Agreement *

Yes

Please read and acknowledge the following *

I understand that by filling this form I am confirming that myself, along with my registered family members will be able to attend the event on December 14. I understand that registering and not attending without emailing a cancellation to yeadon@essexcommunityoutreach.org will negatively affect my chances of receiving complementary tickets and access to events in the future.