First Name:
Last Name:
Email:
Address:
City:
State:
Zip:
Phone:

Reference 1:
Reference 1 Phone:

---

Reference 2:
Reference 2 Phone:

Emergency Contact 1:
Emergency Phone 1:

---

Emergency Contact 2:
Emergency Phone 2:

Will you be here for the whole weekend [Friday evening through Sunday]? Can you come early and/or stay late? We're encouraging affinity groups to come early to prep thoroughly. If you're part of an affinity group, can you?

We have space for tent camping on site. The weather is usually cold up on the mountain this time of year, so you should be prepared for cold weather. If you need alternative housing please let us know so we can try to work that out.

Do you have any medical conditions, allergies or dietary needs we should know about? (e.g. bee sting allergy, nut allery, vegan etc)

Are you currently affiliated with another group or organization working on Appalachian or social justice issues?

Do you have any prior experience in civil disobedience?

Will you need an introductory workshop on MTR and other aspects of the issue?

Have you been to a past Mountain Justice Fall Summit, Spring Break, Summer Camp, Climate Ground Zero event, MTR roadshow or other Mountain Justice events?  Which one(s)?

Are you planning to take part in the mass action? Are you willing to risk arrest?

Any additional information you would like us to know about you?

Folks attending the summit are asked to contribute a minimum of $50 at time of registration. This will help tremendously in planning and purchasing food and supplies and paying for the cost of renting the equipment for the weekend. Any additional contributions will allow us to offer scholarships for those without the funds to attend the summit. If there are any funds remaining after the summit they will be used for ongoing campaigns to fight the destruction of our mountains and communities. Your registration contribution includes camping space, parking, delicious food and all workshops, field trips and sessions. No one will be turned away for lack of funds, just please donate what you can.

---

Contribution Amount:$
Paypal/Credit Card:
Check/Money Order:
I need a scholarship to come to camp:

By submitting this form I agree to abide by the Mountain Justice policy of non-violence/non-property destruction and any rules or requirements asked of us by our host.

***** Our hosts have a zero-tolerance policy on drugs and alcohol. We need everyone sober to make this event safe, and a success. Please don't bring any drugs or alcohol.*****