2017 Arts and Activism Fellowship Application
Thank you for your interest in Willie Mae Rock Camp! Please use this application if you would like to apply for the Arts and Activism Program and Fellowship. The application deadline has been extended to Monday December 5th.


If you have any questions, please call 347-599-0716 or e-mail vivianne@williemaerockcamp.org

Your Legal First Name *
Your answer
Your Legal Last Name *
Your answer
First Name as you would like it to appear in any public materials
If different from legal name
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Age *
At time of fellowship
Your answer
Your Preferred Gender Pronouns *
Preferred Gender Pronouns, or PGPs, are the pronouns that an individual would like other to use when talking to, or about, that individual. Check all that apply.
Required
Current Grade in School *
If currently enrolled in school, if not write N/A for this and the following questions related to school
Your answer
Name of School *
Your answer
Neighborhood of School *
Your answer
This school is *
Your Email Address
If applicable
Your answer
Your Primary Address *
Your answer
City *
Your answer
State *
Your answer
Zipcode *
Your answer
Your Mailing Address
If different than above
Your answer
Mailing City
If different than above
Your answer
Mailing State
If different than above
Your answer
Mailing Zipcode
If different than above
Your answer
FAMILY/CAREGIVER INFORMATION
Primary Parent/Guardian Name *
Your answer
Primary Parent/Guardian's Relationship to You *
Your answer
Does Primary Parent/Guardian live with you? *
Primary Parent/Guardian Main Phone Number *
Your answer
Primary Parent/Guardian Alternate Phone Number
Your answer
Primary Parent/Guardian Email Address *
Your answer
Primary Parent/Guardian Address
If different from camper's primary address
Your answer
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