APPLY FOR QUEER CAMP!

Campers Name *

First Name

Last Name

Campers Birth Date *

MM

DD

YYYY

Campers Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Camper Race *

Please check all that apply to you

Caucasian/White

African-American/Black

Native American/Alaska Native

Asian Native Hawaiian/Pacific Islander

Hispanic/Latino

None of these apply to me

What Session are you applying for? *

Please Note: Sunday Drop Off Hours 9:00 AM - 10:00 AM and Friday Pick Up Hours are 2:00 PM - 3:00 PM.

Session 1: July 7 - 12 (Ages 15-18)

Session 2: July 14 - 19 (Ages 13-16)

Guardian 1 Name

First Name

Last Name

Guardian 1 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Guardian Phone

(###)

###

####

Does the Camper have an IEP or 504 Plan?

Yes

No

Does the Camper Have Any Allergies?

Yes

No

Will the camper require medication?

Yes

No

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

I would like to receive more information about available scholarships.

Yes! I am a CAREGIVER and would like more information.

Yes! I am a YOUTH/CAMPER and would like more information.

No thank you! Please support someone who needs it!