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School of Media Arts Student Application Form

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Student Information

First Name:*

Last Name:*

Current Grade:*


Date of Birth:*


Student's Cell Phone:

Student's E-mail:*

Address 1:*

Address 2:



Zip Code:*


How did you hear about the program:

Parent/Guardian's Information

First Name:*

Last Name:*

Primary Phone:*

Alternate Phone:


Please provide the parent/guardian address if different from the student.

Address 1:

Address 2:



Zip Code:

I, the parent/guardian of the above named student, consent to the release of the information on this application to NYSSSA. I authorize NYSSSA to use my student's name in association with any news releases, and permit the use of any photographs, digital images or videos taken during the audition for publicity or documentation purposes.

School Information

School Name:*

Principal's Name:*

School Phone:*

School Address:*



Zip Code:*

Media Teacher(s):

Teacher's Phone:

Teacher's E-mail:

I am submitting work in:

I am applying for:

In addition to submitting this online form, the applicant acknowledges that they must also submit a portfolio and artistic statement. More information is found at*
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