Breaking Free Camp
Please complete this site location application form for The Breaking Free out of school Camp Program and we'll be in touch. Thank you!
Name
*
First Name
Last Name
Email
*
example@example.com
Number
*
Please enter a valid phone number.
Company or Organization Name
*
Enter EIN# for non-profit organization.
What's your role/title at the company listed above?
Please enter the name of the site location where camp will be hosted?
Site location address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What county is your site location located?
Approximately, how many students plan to attend camp?
Enter your desired camp dates.
Enter your desired camp duration.
9am-11am
11am-1pm
1pm-3pm
3pm-5pm
5pm-7pm
Other
If selected "other" please type your desired camp hours.
Do you require any special accomadations for camp? If so, please list them in the field.
Please list any additional information or questions you may have.
Please select the best date and time to schedule a call or virtual meeting to go over final details for camp.
Do you prefer to chat virtually or via phone?
Virtually, Google meet link will be emailed to you.
Phone
Submit
Should be Empty: