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2024-2025 QUEERY Registration Form
Contact Information
Youth Name
*
First Name
Last Name
Youth Email (optional)
Verify Email
Youth Phone (optional)
Caregiver Name
*
First Name
Last Name
Caregiver Email
*
Verify Email
*
Caregiver Phone
*
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Accessibility Information
QUEERY is a welcoming space for individuals with disabilities. Please do not shy away from participating! We will shape our programming according to the group's varying needs to ensure that activities are accessible for all.
Any accessibility accommodations? We would love to help.
Health Information
Dietary Restrictions
Allergies
Any health conditions we should be aware of?
Youth's Demographic Information
Sharing the following information is entirely optional. You can share as much or as little as you want. If you choose to share this information with us, it will help us track the communities we are reaching. The only required field is participant age.
Age
*
Below age 18
Gender
Trans and/or non-binary
Female
Male
Another gender not listed
Ethnicity/Race
Black/African American
Indigenous/Native American/Alaskan Native
Asian
Native Hawaiian/Pacific Islander
Hispanic/Latine
White
Multiple races or ethnicities
Another race or ethnicity not listed
Disability Status
Yes, I have a disability
No, I do not have a disability
LGBTQIA2S+ Status
Yes, I identify as LGBTQIA2S+ and/or queer
No, I do not identify as LGBTQIA2S+ or queer
Household Income
Below $30,000
$30,000 - $60,000
$60,000 - $100,000
Above $100,000
Liability Waiver
I release and hold harmless Clean River Partners, their partner organizations, and their successors from any and all claims, costs, suits, actions, judgments or expenses upon any damage, loss or injury to me, my child, or my property which may arise from QUEERY events. I acknowledge that I am fully aware of any and all risks posed by these activities and that my child has no medical condition that prevents them from engaging in them. In signing below, I acknowledge that I have read and understand this agreement.
Caregiver: type your full name here to sign the liability waiver.
*
Media Release
I give my permission to Clean River Partners to use any photographs or video recordings taken of me at this event for promotional and educational purposes in any analog or digital format without payment and without obligation or liability to me. I also give my permission to Clean River Partners to use any quotes given by me at this event for promotional and educational purposes in any analog or digital format without payment and without obligation or liability to me.
Media Release Options
*
Yes, I am the caregiver for this individual and I give my permission
No, I am the caregiver for this individual and I do not give my permission
Caregiver: type your full name here to sign the media release.
*
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