Peacebuilders Camp Interest Form
RequiredRequired Question(s)
Required 1.
Contact name:
 

50 characters left.
Required 2.

Organization: 


 

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Required 3.

Contact phone number: 


 

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Required 4.

Contact email address: 

 

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Required 5.

Street address: 


 

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Required 6.

City: 


 

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Required 7.

State:

 

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Required 8.

Zip code: 

 

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Required 9.

Preferred method of follow-up communication: 

Phone
Email
Mail
  • Comment:

  • 500 characters left.
Required 10.
Please select ALL of the Peacebuilders Camp session topics below which you would like to be include in your session. (Topics included will be based on the needs of your campers and time available during your session.)
Communities and Working Together
Self-Esteem and Personal Power
stress and My Brain
Communication and Listening
Conflict Resolution
Responsibility/ Choices and Consequences
Bullying Prevention and Empathy
Acceptance and Inclusion
Social Problem-Solving
Peer Pressure
Persistence and Protective Factors
Hope and Purpose
be the change- How I can improve the world around me! (social, animal, and environmental issues)
Restorative Practices
Required 11.

Anticipated number of participants: 

 

50 characters left.
Required 12.

Please indicate the target audience for the program: 

Preschool Children
Elementary School Children
MIddle School Youth
High School Youth
Youth-serving Professionals
Other  
  • Comment:

  • 500 characters left.
13.

Full and half day sessions will be available on a first come, first served basis from May 30 - July 29, 2017 from 9 am - 4 pm, M-F. Please list the top five dates and times that would work best for your organization's Peacebuilders session at Eagle Creek Park.  

 

350 characters left.
14.
Full-day sessions are $10 per child/youth and half-day sessions are $5 per child/youth. Reduced fees are available on a sliding fee based on the percentage of youth served who qualify for free free or reduced lunches. Please select the option below that works best for your organization:
Our camp/organization is able to pay the regular rates ($10 per child) for a full-day session.
Our camp/organization is able to pay the regular rates ($5 per child) for a half-day session.
Our camp is interested in the sliding fee rates. If you select this option, please indicate the percentage of youth you serve who qualify for the free or reduced lunch program.
  • Comment:

  • 500 characters left.
Required 15.

Please indicate your desired goals/outcomes for your Peacebuilders camp session. (i.e. to help prevent bullying behaviors, etc.) 

 

1000 characters left.
Required 16.

I, or another representative from my organization, will complete an evaluation after our Peacebuilders camp session to help Peace Learning Center measure the impact of the program to create an even better program in the future. 

Yes
No
Other