Climate Camp 2022 Registration

Camper Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Are you able to receive text messages at this number? *

Yes

No

Which Week(s) are you registering for? *

Climate Camp July 11-15

Camper Birth Date *

MM

DD

YYYY

Emergency Contact Phone Number *

(###)

###

####

I also give permission for photos and videos taken of my child at camp to be used for public relations purposes for Peace Learning Center, HEART, and Earth Charter Indiana..

Yes

No

I give my child permission to participate in all phases of the 2021 Climate Camp. In an emergency when neither I nor the emergency contact person named can be reached I hereby authorize the camp director to take any action deemed necessary for the best interests of my child. *

Yes

No

Camper receives free or reduced lunch at school

Yes

No

I am applying for a financial grant to cover the 100 camp fee *

Yes

No

What pronouns do you use for yourself?

They/Them

She/Her

He/Him

Other