NGCJAC Registration Form Next Generation Climate Justice Action Camp Name* First Last Pronoun Preference*he, she, they, zheBirthdate* Email* Phone*Emergency Contacts (2 contacts preferred)*Names & relation to youEmergency contact's phone number*Emergency contact's emailAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country How did you hear about the camp?How would you describe yourself?Whatever you want to share-- like age, gender, race/ethnicity, sexual orientation, class background, ability, native language (do you want an interpreter on site), etc.Please describe any experience you have working with social and environmental issues.*Have you volunteered with groups that focus on social change and environmental issues? If so, what is your experience and which groups did you work with? Have you been to protests or demonstrations? Which ones? What issues are you passionate about and why?What workshops or skills would you like to see at the camp? Examples could include: know your rights, media skills, campaign planning, protest tactics, art, music, etc.Do you have any skills you would like to share?How much time would you need? Any other logistical or support needs? Do you have an special dietary, allergy or medical needs (including accessibility issues)?If none, go to next page. Dietary or Allergy Medical Other Dietary or allergy concerns*Please let us know if your diet is vegan, vegetarian, gluten-free, etc. Also, let us know if you have any allergies or can't be in proximity to any foods, pets, scents, etc.Medical needs*Do you have an inhaler or EpiPen? Does any of your medication require refrigeration?Additional Needs*Let us know of anything else that would improve your NGCJAC experience. If you have specific accessibility or translation needs, please let us know. The cost of the camp is $150.00, but no one will be denied if they cannot afford to pay. Will you be applying for a scholarship or other financial assistance?*There are scholarships and discounts available, as well as travel reimbursements for people with financial need.YesNoWhat type of financial assistance do you need? Full scholarship Partial scholarship Travel Reimbursement What is the amount you are able to pay?Where will you be traveling from?Please describe your financial situation and your need for assistance.We can make the best decisions regarding scholarship allocation when you provide clear and truthful information please. Travel shuttle--we will be attempting to provide a shuttle from at least Portland, Eugene, Northern California. Would you be interested in taking the shuttle to the camp? If so, which location would you leave from?