Summer Camp Form – Tabula Rasa Domestic Violence

First Name *

Preferred Name *

Gender Identity *

Last Name *

Date of Birth *

School Attending *

Grade Level (Fall 2025) *

First Name

Last Name

Relationship to Camper *

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Emergency Contact (if different) *

Phone *

Does your child have any allergies? *

If so, please list

Does your child take any medications? *

If yes, please list

Any medical conditions, disabilities, or accommodations needed? *

Physician's Name *

Physician's Phone Number *

Insurance Provider and Policy Number *

Consent *

I hereby give permission for my child to participate in the TeenSpeakUp Youth Empowerment Summer Camp, hosted by Tabula Rasa Domestic Violence, Inc. I understand that this program is trauma-informed and may involve discussions around healthy relationships, self-expression, and personal development. I give permission for staff to seek emergency medical treatment if necessary.