Youth Retreat Registration

Youth Retreat Registration Summer 2025 Waitlist!

Welcome to our Summer Retreat for Trans and gender Non-Conforming Youth! We're thrilled to invite high school students, as well as recent high school graduates, to join us for an empowering and inclusive experience from July 27th - 30th. This retreat is designed to provide a supportive space where participants can connect, learn, and grow together. We're excited to create memories, foster community, and celebrate the diversity and resilience of our trans youth. Let's make this summer unforgettable!
Please note that all communication is via email!

If the participant would like their guardian to take care of the paperwork and payments - please put the guardian's email as the participant's email!
Your Name (camper):*

First NameLast Name
Phone Number (Camper or guardian)*
Email Address (Primary Communication email for forms and updates)*
example@example.com
Pronouns:*
Grade Level in Fall of 2025*
T-Shirt Size:*
T-Shirt Type:*
Birth Date*

MonthDayYear
Which race or ethnicity best describes you?*
If Multiple ethnicities or Other, please let us know below:*
Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Allergies and Dietary Restrictions
Do you have any allergies or dietary restrictions?*
Select all that apply:*

DairyGlutenGluten - CeliacGrassPollenOther
If Other, please specify:

Family Information
Parent/Guardian's Name*

First NameLast Name
Contact Phone Number*
Relationship to participant:*
E-mail Address*
example@example.com
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Relationship to Participant:*

Wild Heart Society Information
Are you new to Wild Heart Society?:
If yes, How did you hear about us?*
If no, are you or someone in your family a current client with someone at Wild Heart Society or have you been to a group/retreat before? With who?: *
Costs:
This camp with Wild Heart Society will cost $500. This covers meals, snacks, supplies and sleeping arrangements. We have payment plans below should you need one.

We have a few scholarships available to those that are on state insurance.

To help offset costs for the camp, we intend to run health insurance for our time together for 4 therapy sessions (one per day). If there are copays, coinsurances or deductibles, these will be covered by Wild Heart Society. There will be times that the kids meet as a group and we talk about what has been discussed in sessions and they can ask questions as we facilitate a group therapy session.

Please fill out the information below. If you have questions about this, please reach out to our billing team, billing@wildheartsociety.org.
Legal Name (Camper):*

First NameLast Name
Sex (as marked on insurance):*
Insurance Company:*
Member ID:*
Copay/Coinsurance/Deductible amount:*
Please upload a picture of a insurance card below:*

Cancelof
Do you need medication administration paperwork?*
If you select 'Yes' you will be sent seprate paperwork to fill out for each medicaiton, don't worry, it's all one form!
What kind of payment structure works best for you?*

One Payment/Monthly PaymentsI am on Medicaid/Apple Health and I am interested in a possible scholarship - please send me more information
Should be Empty:

Youth Retreat Registration Summer 2025 Waitlist!

Allergies and Dietary Restrictions

Family Information

Emergency Contact Information

Wild Heart Society Information