Camper's First Name: Camper's Last Name: Birth Date: / / Grade 2022-2023 Gender: Cisgender Man Cisgender Woman Transgender Man Transgender Woman Non-binary, gender-queer, two-spirit, intersex Prefer to self-idenity Prefer not to say Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix Parent/Guardian Name: Parent/Guardian Email: Parent/Guardian Phone: Parent/Guardian Address: (if different from child) Emergency Contact Name (other than Parent/Guardian): Emergency Contact Number (other than Parent/Guardian): Emergency Contact Relationship to Participant: Name of deceased person: Relationship to participant: Cause of death: Date of death: What would be helpful for us to know about the circumstances of the death and your child’s response? Or, have any of the circumstances in your family shifted lately? How does your child do in school or group settings? What works best if your child is struggling (with rules, structure, homesickness, anxiety, other)? What are your child's interests? Please check any special considerations, circumstances, needs or requests that your child may have. Anything else we should know to help create a positive experience for your camper? (2024) Race/Ethnicity Black, African, or African American East Asian or South Asian Hispanic or Latinx/a/o Indigenous / First Nations Middle Eastern or North African Native Hawiian or Other Pacific Islander White/Non-Latinx or Caucasian Other Multiple races Prefer not to answer (2024) Do you live in a rural area? Rural is defined by living anywhere outside of Billings, Bozeman, Butte, Great Falls, Helena, Kalispell, or Missoula. (2024) Do you identify with any of the following? (2024) Has a family member or loved one died by suicide? Who may drop off and pick up your child? What is their relationship to your child? Number of Attendees: (please leave at 1) Name of Parent/Guardian signing waiver: