GSA Activist Camp – GSA Network of California

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First Name

Last Name

Birthdate

Pronouns

Legal Name

As it appears on your school or government issued ID

Street Address

City

Genders

Agender

Cisgender Man

Cisgender Woman

Non-binary, Gender Expansive, Genderqueer

Trans Man (FTM Spectrum)

Trans Woman (MTF Spectrum)

Two-Spirit (This term should not be co-opted by people who are not indigenous)

Other (Questioning/Don't know/Decline to State)

Sexualities

Asexual

Bisexual

Gay

Lesbian

Queer

Questioning

Straight

Pansexual/Omnisexual

Other

Race/ethnicity

African/African-American/Black

Asian-American

Latinx or Hispanic

Middle Eastern

Multiracial

Native American/Alaska Native/American Indian

Native Hawaiian/Pacific Islander

White

Other, please specify

Students & GSA Members

Expected Graduation Year (High School)

Name of High School or Middle School you attend

GSA Club Name

How should we contact you?

By registering through our site, you will receive automated emails and may receive additional event or program specific emails. Please use the options below to sign up for additional communication methods.

Communications Preferences

Please send me text messages

Please use the listed phone number to call me

Please use my email address to send me newsletter updates

Activist Camp Questions

Special Room Request

Roommate selection will be based on age, no one under 18 will share a room with anyone over the age of 18, and a review of any special request made here. Special room requests are reviewed and approved based on the safety of our participants. All other concerns will be considered, but there is no guarantee that those request will be approved.

Food Preferences

No Preference

Vegetarian

Vegan

Gluten-Free

Lactose-free

Pescatarian

Allergies

Please list food and non food allergies.

Disability-Related Accessibility Needs

If you are requesting disability-related accommodations, including sign-language interpreters please list the accommodation/s here. Disability-Related Accessibility Needs can be made at any time, but some types of accommodations take several weeks to arrange. Please request accommodations as soon as possible and feel free to follow up with the GSA Staff Member listed on this event.

Medicine: Bring any medication that you take regularly. If you have allergies, bring your allergy meds (We’re looking at all of you with EpiPens). These must not be shared and are for your PERSONAL USE only. You will be responsible for your own medication, unless an adult is required to administer your medication. Staff can hold onto your medication and you should notify them before camp if this is needed.

Are there any medications you are currently taking?

Will you have your own transportation to this event*

Yes

*Answer yes, if you need transportation scholarship to help you to and from the meeting location (i.e. LA Union Station). These meeting location are where those in your region will meet and then be transported to UC Santa Cruz.

Do you need a travel scholarship?

Yes

Do you need a transportation scholarship to help you get to and from the meeting location? (NOT UC Santa Cruz, meeting location is where all others who need transportation to UC Santa Cruz will meet. Final meeting locations to be determined).

Emergency Contact Information

NOTE: If you are under age 18, please provide guardian/parent information in this section. If you are over 18, please provide emergency contact information.

Emergency Contact Name

Emergency Contact Relationship

Emergency Phone Number

Name we should use for you with your emergency contact

Pronouns we should use for you with your emergency contact

1. Activist Camp is an opportunity to learn and grow. Please check off what topics you are most excited about learning about

Power and Oppression

Race

Gender

Sexuality

Class

LGBTQ Movement History

Taking Action

GSA Movement

2. What experiences inform your interest in these topics?

(e.g. As an immigrant trans man, I want to learn about how my immigration status can impact my identity as a Trans person in the United States.)

3. What do you hope to gain from GSA Activist Camp? How will you take back what you learn at GSA Activist Camp to your GSA and local GSAs outside of your school?

4. If you are selected to participate, what activities, practices and materials will create a space that meets all or most of your needs for you to feel safe and present at camp?

5. How have you been involved in your school or local community to address issues/problems? What vision do you have for the future of TQ2S+ Youth in your community?

6. What do you think are the best ways to engage youth in addressing issues/problems they face at school and or in their local communities?

Your Information

Students & GSA Members

How should we contact you?