Anytown Registration Application

Step 1: Fill Out and submit your delegate application

After you click Submit, you will be asked to make a payment or submit a deposit to reserve your spot.

If you need financial aid, please Submit the application and then contact us at hello@inclusioncenter.org . Because of the support from the Anytowners who came before you, our Board, and our community partners, we have never turned an applicant away for inability to pay. Please do not hesitate to contact us about financial aid.

* Indicates required field

Name *

First

Last

Address *

City *

State *

Zip Code *

Highschool *

Date of Birth *

Racial/ Ethnic identity *

Gender Identity *

Faith/ Spiritual identity *

Delegate Phone *

Delegate Email *

Guardian Phone *

Guardian Email *

How did you find out about Anytown? *

To ensure diversity at Anytown, please complete the following:

Do you require any language assistance? *

Do you require any accomodations for physical accesibility or dietary needs? *

Do you require any accomodations for spiritual/ religious worship? *

Medical Information, in case of emergencies
Guardian Contact information

Guardian Name *

First

Last

Guardian Phone Number *

Alternative Phone Number *

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

Emergency contact relationship to delegate *

Has the delegate been seriously injured in the last year and required medical treatment? *

Please list all known allergies: *

Please list ALL over the counter and prescription medications the delegate will be bringing to camp: *

Please list any medical conditions of the delegate/participant: *

Insurance Information
While attending Anytown, applicant is covered by the Inclusion Center’s accidental secondary insurance. This will provide supplementary coverage to your primary insurance.

Does the participant have medical insurance *

Insurance Carrier *

Policy Holder Name *

Holder ID # *

Waivers and Agreements

Emergency Release
In the event of an accident or illness which requires emergency medical care, I understand that every effort will be made to contact guardians of the individual involved. In the vent I cannot be reached, I five my permission to the Inclusion Center staff to transport my dependent to appropriate medical facilities as needed for licensed nurses and/or physicians to order such medical attention as may be deemed necessary for my dependent’s health and safety.

I consent and agree to the emergency release terms mentioned above ( guardian to initial) *

Media Release
I understand the my dependent’s image and/ or personal statements might be publicized and or used by the Inclusion Center and or its approved partners. I also give permission for my dependent’s information (address, phone, email, and school) to be printed in the contact roster for other participants and staff to access after camp.

Does the guardian consent and agree to the media release terms mentioned above? *

Youth Consent
I agree to be present for the ENTIRE program and agree to have respectful and responsible behavior while there. I understand that CELL PHONES ARE NOT ALLOWED. In case of emergency my family may contact Camp Co-Directors, and they will relay the message to me. I understand that no activities are to be engaged in that will endanger other participants or cause damage to the place of training. I understand that I may NOT use Inclusion Center programming or materials outside of the event. I understand that I MAY NOT bring any weapons. I understand that I may not bring or use any drugs, alcohol, or cigarettes at the Event. I understand that I will be required to turn in ALL medications to the medical staff to be distributed by them. I understand that I may NOT engage in any sexual activity while at the event. I understand that I will be required to pay for any damages to the facility for which I am responsible. I understand that if I fail to follow the above mentioned statements, I may be dismissed from the program.
DO NOT SIGN UNLESS READ AND FULLY UNDERSTOOD

Participant Initials *

Guardian Consent
    I understand that my dependent’s participation in an Inclusion Center event or program exposes him/her to risks inherent in camping and youth events. I hereby acknowledge and agree to assume any such risks.
I understand the Event is an intensive human relations program that deals with mature subject matters. I understand that workshop topics may include values clarification, self -esteem, stereotypes, prejudice,s interpersonal communication, racial identity, racism, sexism, sexual orientation, classism, family issues, institutional and personal power, and more. Throughout the week, students may experience confusion, anger, joy, sadness, frustration, hope and more as they learn, I assure you that my child is capable of handling the subject matter and emotional nature of this program.
   In consideration of being permitted to participate in the event, I hereby agree that for my dependent, that I shall hold harmless the Inclusion Center and/or its board members, employees, agents, licensees, or volunteers, from any and all claims, demands, actions, or suits arising out of or in connections with my dependent’s participation in Event, Including those claims which may arise from the negligence of the Inclusion Center, its board, employees, agents, licensees and volunteers.
   The health history is correct and complete as far as I know, and the person herein described has permission to engage in program activities, except as noted. If my dependent’s medical information should change prior to the program, I will notify the Inclusion Center of any new conditions, medication, limitations, etc.
   I understand that CELL PHONES ARE NOT ALLOWED. In case of emergency my family may contact the Inclusion Center at 801.587.0823 and they will relay the message to the applicant. I understand that I may not hold the Inclusion Center responsible for any lost or damaged property.
DO NOT SIGN UNLESS READ AND FULLY UNDERSTOOD

Guardian Initials *

Submit