2018 Arts and Activism Fellowship Application
Thank you for your interest in Willie Mae Rock Camp's Arts & Activism Program and Fellowship! Please use this form if you would like to apply - the deadline is Friday December 15th.


If you have any questions, please call 347-599-0716 or e-mail vivianne@williemaerockcamp.org
Sign in to Google to save your progress. Learn more
Your Legal First Name *
Your Legal Last Name *
First Name as you would like it to appear in any public materials
If different from legal name
Date of Birth *
MM
/
DD
/
YYYY
Age *
At time of fellowship
Your Preferred Gender Pronouns *
Preferred Gender Pronouns, or PGPs, are the pronouns that an individual would like other to use when talking to, or about, that individual. Check all that apply.
Required
Current Grade in School *
If currently enrolled in school, if not write N/A for this and the following questions related to school
Name of School *
Neighborhood of School *
This school is *
Your Email Address
If applicable
Your Primary Address *
City *
State *
Zipcode *
Your Mailing Address
If different than above
Mailing City
If different than above
Mailing State
If different than above
Mailing Zipcode
If different than above
FAMILY/CAREGIVER INFORMATION
Primary Parent/Guardian Name *
Primary Parent/Guardian's Relationship to You *
Does Primary Parent/Guardian live with you? *
Primary Parent/Guardian Main Phone Number *
Primary Parent/Guardian Alternate Phone Number
Primary Parent/Guardian Email Address *
Primary Parent/Guardian Address
If different from camper's primary address
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Willie Mae Rock Camp for Girls. Report Abuse