Mosaic LGBT Youth Summer Camp Register
Fields with red stars are compulsory as this is information we consider crucial.

Make sure you give us as correct information as possible as it might affect allocation of a place.


If you are under 18, did you get parental consent to fill in this form?
You need parental / guardians consent to fill in this form.
First Name of the Camper *
Your answer
Surname of the Camper *
Your answer
Is there another name that you would like us to address you by?
Some people do not like their legal name. We respect that so please make sure you tell us about it here.
Your answer
What gender pronoun would you like us to use? *
Gender Identity of the Camper *
It will help us understand your needs better
Is your gender identity the same as the one assigned to you at birth? *
Majority of population are assigned their sex at birth and their gender identity is the same.
Camper's mobile phone number
Your answer
Camper's current address *
We need it to make sure we can accommodate all the requirements.
Your answer
Campers Date of Birth *
Please make sure you state your year of Birth and not the date of your Birthday :-)
Camper's age on 20th August 2017 *
Your answer
Does Camper have a disability, learning difficulty or impairment we should know about? *
It will help us understand your needs better and meet them while camping. Please note that if you do have special needs and you will not state them here we might not be able to take you on the day as we will not be prepared to meet them and it would have put you at risk! If you have none just state None
Your answer
Do you have any special or dietary requirements? *
Please tell us if you are vegetarian, vegan or what support you need if you have disability or impairment. It is also space to tell us if you have any other arrangements like sleep walking protection for instance.
Your answer
What is your religion or belief? *
That will allow us to accommodate for pray time for instance. Make sure that you say if you are practicing your belief what are your expectations and how we can accommodate your religious practices.
Your answer
Parent's / Guardian's First Name *
We need to know who to inform in case of emergency.
Your answer
Parent's / Guardian's Surname *
Your answer
Parent's / Guardian's Address *
Please provide if different from Camper's address
Your answer
Parent's / Guardian's relationship to the camper *
e.g. mother, aunt, foster parent, social worker
Your answer
Parent's / Guardian's email address
if applicable
Your answer
Parent's / Guardian's telephone numbers *
Please provide landline and work number as well as mobile number
Your answer
Alternative emergency contact? *
Please provide: name, surname, relationship, address and telephone number
Your answer
Camper's National Insurance Number
We don't necessarily need this, but it might be helpful in emergency.
Your answer
Are you able to swim? *
That is very important, please be honest.
The cost of the Summer Camp this year is £377 per person, can you afford it in full? *
Please let us know how much you can afford, we have some funding to help cover part of the costs, but any payments helps us to keep the Camp happening every year.
If you told us you can afford part of the cost please let us know how much is reasonably achievable for you.
Please note that the more you pay the more you help us make this programme sustainable.
Your answer
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms