Summer Institute 2024 Application

Name *

First Name

Last Name

Age *

14

15

16

17

18

19

Phone *

(###)

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Mailing Address *

Please provide an address where you can receive mail.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

###

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Commitment *

I am committed to the full program, including internship (3-4 weeks)

I am unable to commit to the full program, but I am still interested in participating on a drop-in basis when I have availability!

Select the issues you know about (check all that apply). *

Sexual/Domestic/Teen Dating Violence

Racism

Police Brutality

Prison & Detention

Intersectionality

Homelessness

Immigration

LGBTQIA

Differently-Abled Rights

Mental Health

Other:

Which internship track would you be interested in joining? *

Podcast Development

Art and Activism

Creative Writing

This is an in-person program, please be aware that you will be required to follow Covid-19 guidelines: *

I understand and agree