Back-To-Land Interdependence Camp Application

Back-To-Land Interdependence Camp Application
Thank you for your interest in our Back-to-the-Land Youth & Families Mentorship Program weekend camping retreat, taking place at our beautiful farm and forest land in Drain, Oregon. This immersive experience offers families the opportunity to engage in hands-on education in herbalism, forestry, and regenerative farming, while also participating in trauma-informed mentorship, family relationship-building, and emotional well-being practices. We are excited at the possiblity of your family joining us for a transformative weekend that fosters connection with nature, personal growth, and deeper family bonds.

We will be having our B2L Camp on July 3-5, 2026.

Here are some important things to know before you fill out your application:

Each family must have at least one legal guardian present for the camp. All youth participants must be accompanied by a parent or legal guardian who will attend the camp with them for the duration of the event. This ensures that families have the opportunity to connect and support one another throughout the retreat experience. It also ensures that there is a caregiver present onsite to ensure the safety of the youth under their care AT ALL TIMES. Caregivers are not allowed to leave the premises and leave youth unattended for the duration of the weekend.

Please note that while this retreat offers a supportive, safe, and enriching environment, it is not a therapeutic camp and does not act as a substitute for therapy or mental health counseling. Our camps are only aimed as a supplement to any existing wellness practices. If anyone attending this camp is seeking psychological or physical health services, please pursue these through the appropriate medical channels.

The physical and mental health questions included in the application are intended solely to assess the capacity of each participant to participate safely in these community events and/or to identify any specific needs or considerations that may impact participants' experience if they were to join the camp. All information provided is kept confidential and will only be shared with camp mentors and support staff, as necessary, for the care and safety of the participant.

After you complete the application someone on our team will be in touch with you within a couple of weeks. Please remember that space is limited and that filling out this application, does not guarantee a spot at the event. However, we are planning to have ongoing camp weekends in 2026-2027 and will include you on the mailing list for upcoming events if spots run out for the event of your choice.

With infinite gratitude,

The Liberation Pathways Team
Registering Parent/Legal Guardian Name*

First NameLast Name
What do you prefer to be called?
Pronouns*
Primary Contact Number.*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
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Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ADULT PARTICIPANTS

Three adults are welcome to attend per family. Please fill out the following information for each adult participants in your party.
ADULT PARTICIPANT 2
ADULT PARTICIPANT 3
YOUTH PARTICIPANTS

Please fill out the following information for each youth participants who will attend under your care. If there are more than 5 youths in your family, please let us know under ADDITIONAL COMMENTS at the bottom of this application.
YOUTH PARTICIPANT 1
YOUTH PARTICIPANT 2
YOUTH PARTICIPANT 3
YOUTH PARTICIPANT 4
YOUTH PARTICIPANT 5
HEALTH INFORMATION
Do any of the youth or family participants have any physical or intellectual disabilities that might require special accommodations?
Do any of the youth or family participants have any medical conditions or health concerns that the camp organizers should be aware of in order to provide appropriate accommodations?
Do any of the youth or family participants have any food allergy concerns that the retreat organizers should be aware of?
Do any of the youth and family participants take any regular medication?
MENTAL HEALTH CONSIDERATIONS

Please feel free to share as much or as little in this section. The purpose is to ensure that you are supported, since LPHS DOES NOT provide mental health services.
Have any of the youth or family participants ever experienced any challenges (e.g., anxiety, depression, stress, mood disorders, trauma, etc.)?
Do youth or family participants experiencing challenges currently have a mental health support plan, therapist, or counselor?*
Do youth or family participants have any strategies, coping skills, or tools they use to manage the challenges listed? *
Have youth or family participants ever experienced any form of trauma (e.g., emotional, physical, or social)? If yes, would you like to share more about how this may impact their experience during an outdoor, nature-based, community-building camp?*
ADDITIONAL COMMENTS

Please feel free to share anything else you would like to us to know. If your family exceeds 5 youth participants and 3 adult participants, please describe the entire number of your party here.
Additional Comments and/or information
I understand that after my application is reviewed by the LP team, they will contact me to schedule a follow up call. I understand that space is limited and that filling out this application does not confirm or guarantee a space in the camp. I understand that this camp is not a substitute for therapy or medical treatment of any kind. I understand that if participant(s) require psychological and/or medical assistance of any kind, I should obtain these through the appropriate medical channels. I understand that I am responsible for the safety and behavior of the youth that I bring to the camp. I understand the safety guidelines that facilitators/mentors/staff must adhere to. I understand that facilitators, mentors, and staff are mandated reporters who must report any suspicion of abuse involving a minor.*
Signature*
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Back-To-Land Interdependence Camp Application

ADULT PARTICIPANTS

YOUTH PARTICIPANTS

HEALTH INFORMATION

MENTAL HEALTH CONSIDERATIONS

ADDITIONAL COMMENTS