2020 Akili Virtual Family Camp (Nov 13-15) Join us for a virtual weekend of intergenerational healing and strengthening of self, parenthood, youthful joy and where they all intersect. Please complete this form to register everyone in your household for the 2020 Akili Family Camp. Once this application is completed, please be prepared to submit the registration fee. Any applications received without a payment will not be processed (fee is waived for West Oakland Initiative families). The registration fee is $150, per family which you can choose to pay in full or make 3 installment payments in the amount of $50 for 3 months. You will receive a confirmation once your application and payment have been received. Should you need any assistance in completing the application, please contact Denicia Carlay (email@example.com OR (510)876-6087) and she will assist you in any way possible. SPACE IS LIMITED. REGISTRATION DEADLINE IS OCTOBER 25TH REGISTRATION PROCESSPlease complete this form to register everyone in your household for the 2020 Akili Family Camp. The priority registration deadline is October 25, 2020. Please note that space is limited, but a waitlist will be created once capacity is full. CAREGIVER SECTIONPlease answer the questions below regarding all of the caregivers that will be participating in Family Camp. Caregivers can consist of any adults in the home that are responsible for taking care of the youth that reside with them. Caregiver A - Name* First Last Caregiver A - Gender Identity*This is your personal perception of your gender, which may or may not correspond with your sex at birth.Caregiver A - Date of Birth* Date Format: MM slash DD slash YYYY Caregiver A - Race*Please select all of the racial groups you identify with Black/African American Indigenous/Native American European/Caucasian Latinx/Hispanic Asian Native Hawaiin or Pacific Islander Other Caregiver A - Cell Phone Number*Caregiver A - Email Address* Enter Email Confirm Email Caregiver A - Occupation*Caregiver A - What is your relationship to child(ren) attending Akili Family Camp*Caregiver A - Are you familiar with any of these apps?* GroupMe Slack WhatsApp None of the above Caregiver B - Name First Last Caregiver B - Gender IdentityThis is your personal perception of your gender, which may or may not correspond with your sex at birth.Caregiver B - Date of Birth Date Format: MM slash DD slash YYYY Caregiver B - RacePlease select all of the racial groups you identify with Black/African American American Indian/Native American White/Caucasian Latinx/Hispanic Asian Native Hawaiin or Pacific Islander Caregiver B - Cell Phone NumberCaregiver B - Email Address Caregiver B - OccupationCaregiver B - What is your relationship to child(ren) attending Akili Family CampCaregiver B - Are you familiar with any of these apps? GroupMe Slack WhatsApp None of the above CAREGIVERS, PLEASE ANSWER THE FOLLOWING QUESTIONS TOGETHER(If there is more than one caregiver registering for Family Camp, please include both of your responses in open spaces provided below)Has any member of your family ever experienced any of the following programs affiliated with Flourish Agenda?* Oakland Freedom School Camp Akili Caregivers Retreat West Oakland Initiative None of the above Is either caregiver currently a West Oakland Initiative family?*YesNoFamily Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact Name*Please list a person we can contact in case any member of your family is in a state of emergency. First Last Emergency Contact Phone*Due to Alameda County still sheltering in place, Akili Family Camp will be fully virtual in our efforts to keep everyone safe. As such, it's very important for us to know what your general technology capabilities are and if you require any technology accommodations that we can help with?*For example: Are you familiar with how to navigate zoom (including muting yourself and going into breakout rooms), do you have access to a laptop or tablet at home (or need one), do you have stable internet access, etc?Are you in need of a safe, quiet space to stay at outside of your home during the Family Camp weekend? If so, please let us know and the reasons why:* What are you MOST interested in learning about at Akili Family Camp?*Do you have any fears or worries about participating in Family Camp?*What are some techniques that you use to take care of yourself when you are in crisis or are experiencing stress/trauma?*What are some techniques that you know your child(ren) have to take care of themselves when they are in a crisis or are experiencing stress or trauma?*Please be sure to name at least one technique/tool/resource for each of your children. Feel free to ask them directly if you are unsureDo you or your child(ren) have any allergies, use any medications and/or have mental health elements we should be mindful of when working with you?*This can include food or general allergies, medical or psychotropic medications, diagnosed mental health disorders or general symptoms that you feel daily that are not formally diagnosed by a medical/mental health professional. Are there any family dynamics of abuse, neglect, or violence that we should be mindful of when working with your family?*If yes, please share as much as you feel comfortable sharing with us and know that the information provided will only be used to plan for your safety during the Akili Family Camp weekendYOUTH SECTIONParticipants*Please include the following information about each childFirst NameLast NameDate of BirthCell Phone # The Youth section of Akili Family Camp will also include Instagram. Please list your child's IG handle and any other social media names they would like to include here:Hospital/Medical Group Planie: Kaiser, PPO, etc. Hospital/Medical Group Plan Number for each family member attending Family CampMedical Release* I consent In case of emergency I give consent to the staff of Flourish Agenda to seek medical care on behalf of myself or for my child.PAYMENT INFORMATIONRegistration Payment Type*Only select one payment type.Full Payment - $150.003 Installment Payments - $50.00Registration Total to be Paid Now $0.00 ACKNOWLEDGEMENT: I, parent/guardian of the above named youth, give permission for my youth to participate in the 2020 Akili Family Camp and/or Flourish Agenda activities. I understand that Akili Family Camp addresses serious subject matters and social issues, sometimes using graphic content, experiential activities and emotionally intensive conversations. I give permission for media release with the understanding that any photos, articles, participant work, video footage, etc from my youth or from myself may be used for promotional purposes. I understand that if I or my youth refuse to participate respectfully, it could result in their removal from the Akili Family Camp / Flourish Agenda program. I understand that Flourish Agenda staff, counselors, facilitators and volunteers will take the utmost care of my family, and in the unforeseen event of lost or damaged property, or unavoidable injury or death to me or my child, I will not hold the Akili Family Camp / Flourish Agenda or its staff / board members / volunteers / facilitators / counselors liable. I understand the goals of the Akili Family Camp and gladly support my family, and the Akili Family Camp / Flourish Agenda staff, volunteers, counselors, facilitators, in achieving these goals.* I Agree Refund/Cancellation PolicyFlourish Agenda can provide a refund for individual registration fees less a $50 administrative cost for up to 30-days prior to start of camp date. Cancellation request within 30-days of the camp cannot be honored.