Breaking Free Summer Program
Please complete this site location application form for The Breaking Free Summer 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.
Organization Name
What's your role/title at the company listed above?
Please enter the name of the site location where summer camp will be hosted?
To receive 20% non-profit discount please enter EIN#
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?
Select your desired camp dates:
June 3-7
June 10-14
June 17-21
June 24-28
July 8-12
July 15-18
July 22-26
July 29-August 2
August 5-9
Other
If selected "other" please type your desired camp dates.
Please select your desired duration of camp hours. You may select multiple time frames just in case one isn't available.
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: