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Project R.E.S.P.E.C.T Delegate Application
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Delegate Application
Delegate Name
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School Name
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What grade will you be enetering in September 2025
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Address
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City
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State
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Zip Code
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Date of Birth
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Age (what is your age as of today?)
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Phone Number
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Email Address
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Parent/Guardian Name(s)
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Best Number to Contact Parent/Guardian(s)
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Parent/Guardian Email Address
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Does Parent or Guardian Speak English?
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If no, what language?
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Preferred way to contact Parent/Guardian?
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Delegate T-shirt size
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Self-Identity
Gender
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School
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School Class
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Are you Hispanic or Latinx?
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Please Indicate How You Identify Yourself
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If other, please indicate
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About You
Cultural Background
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Religious or Spiritual Identifications?
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Do you have any dietary restrictions?
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If yes, please describe
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Do you belong to any clubs/organizations?
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If yes, please describe
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Do you play any sports?
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If yes, please describe
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What languages do you speak?
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Any previous leadership experience? Do you regularly volunteer?
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If yes, please describe
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How did you learn about Project R.E.S.P.E.C.T? If it was a person, please tell us their name
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List three things about yourself that people would be surprised to know
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Short Essay (OPTIONAL)
One to two paragraph essay should include what your expectations are for Project RESPECT, three goals you will work towards while at Project RESPECT, and what you plan to do with the skills and experiences you gain at Project RESPECT after camp ends.
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Health History and Medical Release Form-In case of emergencies
Applicant's Name (Last, First, Middle)
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Home Address
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Parent/Guardians Name
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Home Language
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Parent/Guardians Daytime Phone
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Parent/Guardians Evening Phone
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1st Emergency Contact Name
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1st Emergency Contact Phone Number
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1st Emergency Contact Relationship to Delegate
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2nd Emergency Contact Name
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2nd Emergency Contact Phone Number
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2nd Emergency Contact Relationship to Delegate
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Name of personal physician
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Phone Number to Personal Physician
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Does the applicant have physical limitation that will restrict participation in program activities?
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If yes, please explain
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Has this applicant been injured and needed medical treatment within the last year?
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If yes, please explain
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Has the applicant previously undergone professional counseling or therapy?
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If yes, please explain
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List all Allergies to Medication (describe reaction and management of reaction)
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List all Allergies to Food (describe reaction and management of reaction)
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List all Other Allergies (describe reaction and management of reaction)
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Please list all medications (describe the dose, time of day taken, and reason for taking each medication)
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Does the applicant have any of the following medical conditions? (Check all that apply)
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Parent or Guardian Authorization
Parent/Guardian Electronic Signature (Please Type Your Full Name)
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Insurance Information
Does the applicant have medical/hospital insurance?
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If YES, indicate the insurance carrier/ plan name
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Policy Holder of Insurance (if other than the applicant)
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Relationship of the Policy Holder to the Participant
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Emergency Release Form
Parent/Guardian Electronic Signature (please type full name)
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Applicant Agreement
Applicant Electronic Signature (please type your full name)
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Parent/Guardian Electronic Signature (please type your full name)
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To secure your application, a deposit of $100 is required.
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Program Participation Consent Form
Applicant Electronic Signature (please type full name)
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Parent/Guardian Electronic Signature (if applicant is under 18, please type full name)
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Media Release
Applicant Electronic Signature (please type your full name)
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Parent/Guardian Electronic Signature (if applicant is under 18, please sign your full name)
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Financial Aid Form
Parent/Guardian Name
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Marital Status
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Parent/Guardian(s) racial/ethnic background(s)
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Parent/Guardian(s) Cultural Background and/or nationality
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Highest Level of Education Completed by Parent/Guardian(s)?
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Including yourself, how many people are in your household?
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How many children in your household are under the age of 18?
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Age of Youngest
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Age of Oldest
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How many children in your household are currently attending college?
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Please indicate your approximate yearly household income before taxes (include total income of all adults living in your household)
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Parent/Guardian(s) currently employed?
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If yes, where do they work?
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Do you or a member of your family qualify for (please indicate all that apply)
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