Name *

First Name

Last Name

Age *

14

15

16

17

18

19

Phone *

(###)

###

####

Mailing Address *

Please provide an address where you can receive mail.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Commitment *

I am committed to the full program, including internship (6 weeks)

I am unable to commit to the full program, but I am still interested in participating on a drop-in basis when I have availability!

Select the issues you know about (check all that apply). *

Sexual/Domestic/Teen Dating Violence

Racism

Police Brutality

Prison & Detention

Policy & Elections

Homelessness

Immigration

LGBTQIA

Differently-Abled Rights

Mental Health

Other:

Which internship track would you be interested in joining? *

Community Organizing for Justice

Radio/Digital and social media marketing

Creative Writing

Do you have access to a laptop/tablet? *

Yes

No

Do you have access to reliable WIFI? *

Yes

No

If you answered "no" to any of the above, would you want access to a (check all that apply):

Laptop

WIFI hotspot