Summer & School Break Camp Registration Request Form

Member's Name *

First Name

Last Name

Member's Birthdate *

MM

DD

YYYY

Name of Person Filling Out This Form *

First Name

Last Name

Your Phone Number *

(###)

###

####

Your Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Which weeks would you like to register for? *

Midwinter Break Camp: February 17-20 from 2-5pm (Teens & Young adults ages 13+)

Spring Break Camp: April 14-17 from 10am-1pm (Teens & Young Adults Ages 13+)

Spring Break Camp: April 14-17 from 2-5pm (Teens & Young adults ages 13+)

Are you planning on using DDA Respite Funds to pay for this camp?

Yes

No

Which of the following best represents the group member's race?

Please check all that apply

American Indian/Alaska Native

Asian / Asian-American

Black / African American / African

Middle Eastern / North African

Native Hawaiian / Pacific Islander

White

Other / Not Listed

Prefer Not to Say

Unknown

Does this group member identify as Hispanic / Latinx?

Yes

No

Prefer Not to Say

Unknown

What language do you prefer to speak at home?

American Sign Language

Amharic

Arabic

Chinese - Cantonese

Chinese - Mandarin

English

Korean

Russian

Somali

Spanish

Ukranian

Vietnamese

Other

Prefer Not to Say

Unknown

What gender does the group member identify as?

Female

Male

Non-Binary

Self-Describes in Another Way

Prefer Not to Say

Unknown