Apply for a Class

We're excited for you to join the Pablove Shutterbugs family!

Pablove Shutterbugs, the signature arts program of The Pablove Foundation, teaches children living with cancer to develop their creative voice through the art of photography. Learning photography concepts alongside other kids undergoing similar experiences empowers our students to express themselves, exercise their independence, and practice new ways of seeing the world – all while having fun! Classes are provided for pediatric cancer patients ages 6-18 years old. All camera equipment is provided by The Pablove Foundation at no charge.

Photography Program Details:

What We Offer: In-person and online virtual classes in digital photography.
Cost: The program is offered FREE of charge to all participants!
Classes: During each class students learn a new lesson in photography concepts and technique
Supplies Provided: We will supply each child with the camera kit and supplies needed for the program
Photo Projects: Students will complete weekly photo assignments
Graduation: The last day of class is graduation, where we celebrate our students’ accomplishments with a ceremony and presentation of their work. Family and friends are invited to attend
Gallery Show: Student work will be exhibited at a public exhibition in a professional gallery in the future. All net proceeds from print sales directly benefit Powered By Pablove pediatric cancer research grants

Our spring 2023 Class info

in-person

Best for students that want in-person engagement and can commute to class.

Available in 2 cities

Los Angeles:
April 15, April 22, April 29, May 6 + May 13

New York:
April 22, April 29, May 6, May 13 + May 20

virtual

Available to any student, regardless of where they live or are receiving treatment. Best for students that are in-patient or cannot access in-person class locations. Requires access to internet and computer, tablet, or smartphone with a webcam.

Available in ALL cities

Orientation:
April 1

Classes:
April 15, April 22, April 29, May 6, May 13 + May 20

Pablove Shutterbugs Student Application

"*" indicates required fields

Session You Are Applying For*

Have you been enrolled in a Pablove Shutterbugs class before?*

Yes

Student Information

Student Name*

First Last

Student Date of Birth*

Student Age

Student Gender*

Male

Female

Non-binary

Student Email Address

Student Cell Phone

Primary Language Spoken by Student*

Student T-Shirt Size*

Each enrolled student will receive a free Pablove Shutterbugs T-Shirt! Please specify student's T-Shirt size:

Parent / Guardian Information

Parent / Guardian #1 Name:*

First Last

Parent / Guardian #1 Email*

Parent / Guardian #1 Cell Phone:*

Primary Language Spoken by Parent/Guardian #1*

Parent / Guardian #1 Relationship to Student:*

Parent / Guardian #2 Name:

First Last

Parent / Guardian #2 Email

Parent / Guardian #2 Cell Phone:

Primary Language Spoken by Parent/Guardian #2

Parent / Guardian #2 Relationship to Student:

Preferred Parent/Guardian Method of Contact*

examples: Dad's cell, Mom's email

Primary Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact Information

We will always contact the parents first in case of emergency. However, please provide contact information for someone else in case we cannot reach the primary parent/guardians. For example: aunt, cousin, brother, neighbor, friend, etc.

Emergency Contact Name*

Relationship to Student*

Phone Number*

Emergency Contact One

Emergency Contact Two

Relationship to Student

Phone Number

Emergency Contact Two

Referral

How did you hear about Pablove Shutterbugs?*

Please list the full name of the person who referred you:*

Technology Requirements

In order to participate in the Pablove Shutterbugs virtual photography program, students/families must have access to the following:

Internet
Computer, tablet, or a smartphone with a webcam
Personal email address

Do you have access to:*

(Please check all that apply)

Internet Connection

Computer with Webcam

Tablet with Webcam

Smartphone with Webcam

School or Personal Device?*

School Provided

Personal

Is your device personal, or school provided? (Example: for a School provided Chromebook select School)

Any additional notes about technology access that you would like us to know:

Student Medical Information

Your medical information will be encrypted and only accessed by a limited number of staff members for the purposes of verifying your program eligibility and ensuring appropriate procedures are followed in the class environment.

Oncology Diagnosis*

Date of Diagnosis*

Other Diagnosis*

Primary Hospital*

Primary Physician's Name*

Primary Physician's Phone Number*

Oncologist's Name*

Oncologist's Phone Number*

Are you still receiving treatment?*

Yes

What was the date of your last treatment?*

Allergies*

Medications, foods, etc.

Please answer the following questions so we are able to accommodate your needs during class:

Do you use a wheelchair, walker or cane?*

Yes

Sometimes

Do you have difficulty speaking clearly?*

Yes

Sometimes

Do you have good use of both hands?*

Yes

Do you have a vision or hearing impairment?*

Yes

Please list any special assistance you may need during class:

Confidential Demographic Information (optional)

The Pablove Shutterbugs program is made possible through generous donations and grants from public and private organizations. Please complete the following information, which helps our prospective donors evaluate our programs. This information is for demographic purposes only, and will remain confidential. The Pablove Foundation will never use your name in association with your responses or to determine program eligibility.

Household Income*

Ethnic Background*

American Indian/Alaska Native

Black/African American

Native Hawaiian/Pacific Islander

Asian/Asian American

Hispanic/Latino

Middle Eastern

Caucasian/Anglo American/White

Other

Decline to State

Other Ethnic Background*

Consent Waivers

Participation Consent/Release*

I have read and agree to the participation consent/release.

The student listed on this application has my permission to participate in the Pablove Shutterbugs program.

In consideration of the Student being permitted to participate in the Pablove Shutterbugs program , I, as parent or legal guardian on behalf of myself and the Student, or Student, individually (Releasors) hereby waive, release, discharge (i.e., give up), and covenant not to sue the Pablove Releasees for any Liability that may arise at any time relating to the Student's participation in the Pablove Shutterbugs classes or the Pablove Shutterbugs program. "Liability" includes all claims, demands and causes of action of any kind and all damages of any kind (including attorneys’ fees and costs), including but not limited to death, personal injury, property damage, or other loss, whether arising out of negligence, strict liability, or carelessness on the part of the Pablove Releasees or any other person or entity. The "Pablove Releasees" are (a) The Pablove Foundation (“Pablove”), and its employees, directors, officers, volunteers, and any and all agents of the Pablove Shutterbugs program, (b) any medical institutions affiliated or assisting in any way the Pablove Foundation, and (c) all third parties affiliated or assisting the Pablove Foundation and/or the Pablove Shutterbugs program in any way, . RELEASORS FURTHER AGREE TO DEFEND, INDEMNIFY AND HOLD HARMLESS PABLOVE RELEASEES FROM ALL LIABILITY.

I authorize and consent to the disclosure and use of the Student's medical diagnosis and other medical information to determine the Student's eligibility and any limitations or restrictions to participation in the Shutterbugs program. In addition, the Student’s diagnosis code may be included in unidentified, confidential periodic survey instruments. Data from these surveys will be reviewed and used in research-based program evaluation. Student information will be unidentified to ensure privacy and confidentiality. Participation in surveys is voluntary and will in no way affect the student’s ability to participate in the program. The purpose of the surveys is to assess the impact of the Shutterbugs classes, to measure quality of life impacts on our students through the Shutterbugs curriculum, and to support further research and program growth. The unidentified data will be kept by Pablove indefinitely.

My physician, as well as his/her authorized representatives, is authorized to fill out, and provide to Pablove any forms that Pablove may require; including forms relating to student's medical eligibility, the requested activity, and related medical considerations.

In the event that Pablove organizes an in-person gathering of any type for and with the Students, and the Student's parent or guardian is not present, I authorize an agent of The Pablove Foundation to obtain emergency medical treatment for the Student as required, and release The Pablove Foundation from any Liability associated with such medical treatment. In all other (non-emergency) circumstances in which the Pablove Shutterbugs participant may need medical care while participating in the Pablove Shutterbugs program, I hereby consent to the provision of first-aid care to the participant as deemed appropriate and necessary until I can be contacted to consent to further treatment (if any is needed).

I hereby represent that the Student is of sufficient health to participate in Pablove Shutterbugs classes and that there are no medical restrictions that would prevent or limit the Student's participation.

These consents will remain in effect for as long as the Student is participating in the Pablove Shutterbugs program.

Expectations of a Participant, Parent/Guardian and Household Members*

My family and I have read the statement below and agree to abide by the expectations.

We expect our program to be the best of its kind. In order for your classes to be safe, fun, and enjoyable for all, we have some expectations we would like you to review before going to your first class.

We expect each participant to treat the instructor, volunteers, and fellow classmates with mutual respect and consideration.

We ask that you attend each class to the best of your ability and notify us in advance if you cannot make classes due to medical or any other reasons. If you cannot attend a class, you must notify Pablove staff or your instructor prior to class.

We ask that the Student comes to class on time and completes their photo assignments in a timely manner.

During any Pablove activity, the use or possession of alcoholic beverages, cigarettes, drugs, or sexual activity by participants is not allowed.

Pablove only reveals personal information about you or your medical history to volunteers on a need to know basis. However, we welcome your comments on how to do this best, and will adjust as necessary to address your concerns.

If you are unable or choose not to continue with your classes you must contact Pablove staff to make the appropriate changes as soon as practical. You may be asked to return any unused materials and equipment back to the foundation.

Pablove provides equipment and materials to students for use during their classes to enhance the learning experience. We ask that you take good care of your equipment and materials so you may enjoy the classes to their fullest degree possible.

Throughout the duration of the entire program, only Pablove Shutterbugs students are permitted to use the cameras they are given.

Pablove reserves the right to terminate participation if any of these expectations are not met.

Please respect the guidelines we have set in place, as they are designed to maximize your experience and provide you with the most beneficial learning environment. If unacceptable behavior continues, your participation in the program will be restricted.

Student Name and Likeness and Work Product Consent Agreement*

I have reviewed the student name and likeness and work product consent agreement and agree to the terms.

The student on this application hereby irrevocably and perpetually grant to The Pablove Foundation (“Pablove”) the right to use my image, voice and likeness (collectively, “Contributions”) for all unrestricted purposes as Pablove may see fit, including fundraising activities. This may include screenshots and recordings of participants in virtual classrooms or video conferences or third party events to which Pablove and you were invited. I further understand and agree that Pablove shall own all rights to any photographs, recordings, films, books, pamphlets, brochures and other written media or materials based in whole or in-part on my Contributions.

I hereby irrevocably and perpetually grant to Pablove a worldwide, royalty-free, exclusive license to (a) use, reproduce, distribute, display and perform (whether publicly or otherwise), publish, prepare derivative works of and otherwise modify, make, commercialize, sell, offer to sell, import and otherwise use and exploit (and have others exercise such rights on behalf of Pablove) all or any portion of any photographs taken by me during my involvement in the Pablove Shutterbugs Program, by themselves or in combination with other items, in any form or media (now known or later developed) including electronic format; and (b) modify all or any portion of such photographs, including, without limitation, the making of additions to or deletions from such photographs, regardless of the medium (now or hereafter known) into which such photographs may be modified and regardless of the effect of such modifications on the integrity of such photographs. The rights granted to Pablove include the right to sublicense such rights. I further grant Pablove the right to use, at Pablove’s sole discretion, my name and likeness in association with the photographs in published form and in advertising and promotional materials.

I hereby waive any right that I may have to inspect and/or approve the finished product or products or the editorial, advertising, or printed copy that may be used in connection therewith and any right that I may have to control the use to which said product, products and/or copy may be applied. I understand that I will not receive any compensation for any publication or broadcast of these materials.

I hereby release, discharge and agree to save Pablove and their legal representatives and assigns from any liability by virtue of any blurring, distortion, alteration, optical illusion or use in composite form, whether intentional or otherwise, that may occur or be produced in the making, processing, duplication, projecting or displaying of said picture or images, and from liability for violation of any personal or proprietary right that I may have in conjunction with said pictures or images and with the use thereof.

This field is for validation purposes and should be left unchanged.