PtC Global Break: Spring 2020 REGISTRATION FORM
About Peace thru Culture Global Break

Dates: April 13 - 17, 2020 - DAILY 10AM - 4PM
Ages Accepted: Girls Ages 12- 16
Location: 4200 Kansas Avenue NW, Washington D.C 20011 (Petworth Neighborhood Library)

This week-long Global Break program provides an alternative Spring Break for youth who are interested in exploring their rich cultural heritage, as well as the culture of Washington DC. Participants will experience unique and diverse cultures through food, the arts, and people to people exchanges. In addition, youth will participate in civic engagement activities and visits to local universities to learn about global study opportunities. The entire week will be punctuated with vlogging, blogging and social media training!

Peace thru Culture has hosted PtC Corps and Camps for more than a decade.

THERE IS A $5 ACTIVITY FEE COLLECTED EACH DAY OF THE PROGRAM.
Email address *
Section 1: Youth Information
Youth's Full Name *
Your answer
Address *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
School Name *
Your answer
Grade Level *
What ethnic group does the youth identify with? *
Your answer
Section 3: Essay
The youth must complete this section. Students will be selected based on this short essay and information provided below.
In 50 words or less, let us know why you would like to attend the PtC Global Spring Break. *
Your answer
Section 4: Parent/Guardian Information
This section is about the student's parent/guardian.
Parent/Guardian #1 Name *
Your answer
Parent/Guardian #1 Address *
Your answer
Parent/Guardian #1 Phone Number 1 *
Your answer
Parent/Guardian #1 Phone Number 2
Your answer
Parent/Guardian #2 Name *
Your answer
Parent/Guardian #2 Address *
Your answer
Parent/Guardian #2 Phone Number 1 *
Your answer
Parent/Guardian #2 Phone Number 2
Your answer
Section 5: Emergency Contact Information
Emergency Contact Name *
Your answer
Relationship to Emergency Contact *
Your answer
Emergency Contact Phone *
Your answer
Section 6: Youth's Medical Information
Insurance Company Name *
Your answer
Insurance Card Name *
Your answer
Name of Primary Card Holder *
Your answer
Allergies or Special Requirement *
Your answer
Epi Pen Requirement? *
Section 7: PARENT STATEMENT
Please read the following statements.
I hereby state that the youth participant stated above is in good health and physical condition and is capable of participation in the PtC Global Winter Break Program - Peace thru Culture, and designated field trips throughout the week of February 17-21, 2020 between 9am – 4pm. *
Required
Waiver of Liability and Hold Harmless: As the legal parent/guardian specifically release Peace thru Culture, its students, agents and employees from any claims or liabilities of any kind whatsoever, arising from or related to my participation in these activities. *
Required
Photo Release: I agree to grant to Peace thru Culture and its authorized representatives permission to record on photography film and/or video, pictures of my participation. I further agree that any or all of the material photographed may be used, in any form, as part of any future publications, brochure, or other printed materials used to promote Peace thru Culture, and further that such use shall be without payment of fees, royalties, special credit or other compensation. *
Required
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