Build a Village; Save the Earth
Your phone number/email?
Where are you currently living? City and state
Are you coming as part of a group? If so, list your primary contact.
Can you commit to not being under the influence or possession of drugs and/or alcohol, nor committing acts of violence (physical, emotional or sexual) and respecting all people while at the camps, as violation of these commitments can endanger the movement and will result in your immediate removal from the camp? (Also we ask that you respect decisions made by the tribe, including the decision to remove you from the camp at any time and prohibiting children from occupying the camp for their safety.) *By answering this question you making a commitment to honor this agreement.
What interested you in being a part of the camp/background?
What is your experience with direct action?
Any other experience that you feel qualifies you for joining the camp?
List any references or any persons that can vouch for you. (Include full name, email and working phone number.)
Spiritual healer or traditional medicine person
List a next of kin contacts (Include full name, email and working phone number, valid address).
Emergency Contact 1 (Include full name, email and working phone number)
Emergency Contact 2
Emergency Contact 3
Other information you would like to add?
List or explain tentative dates of arrival or departure or preference.
How is your health? List health (mental and physical) concerns or allergies?
Do you have health insurance? What kind? This is for you safety. We recommend you purchase health insurance while at the Village?
Send me a copy of my responses.
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