CODEPINK : SUMMER IN NEW ORLEANS/WORK & TRAINING CAMP

* First Name

* Last Name

* Email

Phone

Cell Phone

Work Phone

Home Fax

Street

* City

State

* Zip

Occupation (if retired, please state from what field)

Employer

Ethnic Background (optional)

Why do you want to go to this destination?

What do you expect to gain from participating?

Please state the ways in which your work or studies relate to the issues or

How will you share your learning experience when you return home?

Do you have any special dietary or medical needs?

Do you have any specialized skills (i.e. carpentry, electrician, therapy, etc)?

At times we are able to arrange private meetings for travelers, in addition to the general itinerary of the group. Is there a particular person or organization you would like to meet?

In order to facilitate post-tour communication, we send each member of the group a list of fellow participants’ contact information. If you do not want to be on this list, please check here

Name of person to be contacted in case of emergency:

Emergency Contact's Relation to you:

Emergency Contact's Email:

Emergency Contact's City

Emergency Contact's State:

Emergency Contact's Day Phone:

Emergency Contact's Evening Phone:

First Name

* Required Field