Contact Information
First Name:
Last Name:
Street Address:
City:
Postal Code:
Telephone:
Email address:
Organizational affiliation (if any):
Donation: Suggested donation for the weekend is $20 - $50 (including meals) but no one will be turned away due to lack of funds. Please make cheques payable to Greenpeace Canada (send to Greenpeace, Attn: Angela Woodcock, 33 Cecil Street,Toronto, ON M5T 1N1) or pay cash at the camp.
Food restrictions and/or medical conditions that we should know about:
Transportation: We are car pooling to get there
I need a ride
I can provide a ride
No. of passengers for a ride:
Background in climate change or other environmental issues:
Background knowledge is not required, but telling us about your background, if any, will help us to design our workshops.
Previous Experience:
Do you have previous experience with environmental organizing or other civil disobedience? Experience is not required, but telling us about your experience, if any, will just help us to design our workshops.
Emergency contact information:
Name of contact person:
Phone number
Ext.
Relation to you
References
Because the Climate Action Camps are providing civil disobedience training, which may lead to acts of civil disobedience, participants must provide a reference in the environmental or social justice community who can vouch for you.
Name of Reference:
Phone number
Ext.
Relation to you
Agreement:
In submitting this waiver form, I release Greenpeace from any claims or responsibility for injuries or death suffered during or pursuant to the Climate Action Camp. I knowingly assume all risks associated with participation, even if arising from the negligence of the participants or others, and assume FULL responsibility for my participation. Further, I authorize the camp facilitators to request medical treatment as necessary to insure my well being.
I agree
CC me for my records.
