DIRTY HANDS CARAVAN
Online Registration Application


*required

YOU MUST BE AT LEAST 18 YEARS OLD TO REGISTER. PLEASE TELL US YOUR AGE AND DATE OF BIRTH:

*AGE:

*D.O.B.:

month / day / year

*FIRST NAME:

*LAST NAME:

*ADDRESS:

*CITY

*STATE

*ZIP:

*EMAIL:

*CELL#:

*EMERGENCY CONTACT:

 

EACH INDIVIDUAL MUST COMPLETE A REGISTRATION FORM, IF YOU ARE PLANNING TO JOIN THE CARAVAN WITH OTHERS, PLEASE LIST THEIR NAMES HERE:

 

CARAVAN REGISTRATION INCULDES ROUND-TRIP TRANSPORTATION FROM COACHELLA TO NEW ORLEANS, RETURNING TO LOS ANGELES. PLEASE CHECK HERE IF YOU DO NOT REQUIRE A SEAT ON THE RETURN TRIP.

I do not require a return seat

 

PLEASE WRITE A BRIEF STATEMENT ABOUT WHY YOU WANT TO PARTICIPATE IN THE DIRTY HANDS CARAVAN, INCLUDING ISSUES YOU ARE CONCERNED ABOUT, YOUR OWN INVOLVEMENT IN ACTIVISM AND/OR COMMUNITY SERVICE AND YOUR PERSONAL LIFE GOALS.

 

 

DO YOU HAVE ANY SPECIAL DIETARY NEEDS WE SHOULD KNOW OF?

I’m omnivorous, just feed me.

I’m vegetarian but eat dairy.

I’m strictly vegan.

Kosher

Other, please explain:

 

DO YOU HAVE ANY MEDICAL OR PHYSICAL CONDITIONS THAT WE SHOULD KNOW OF TO ENSURE YOUR WELLBEING AND SAFETY DURING THE CARAVAN?

No

Yes, please explain:

If you know your blood type, let us know:

 

SORRY, BUT WE CANNOT ACCOMMODATE PETS ON THE CARAVAN, WE WILL MAKE OUR BEST EFFORT TO ACCOMMODATE INDIVIDUALS WITH SERVICE ANIMALS. DO YOU HAVE A SERVICE ANIMAL?

Yes, I have a service animal: (please explain)

 

WE WILL BE CAMPING DURING THE CARAVAN, PLEASE BRING YOUR OWN TENT. IF YOU DON’T HAVE A TENT, LET US KNOW NOW.

I will bring my own tent.

I will not be bringing my own tent.

 

(Downloadable waiver coming soon. Check back later)

SPACE ON THE BUSES IS LIMITED, PLEASE BRING ONLY WHAT YOU NEED,
BUT DON’T FORGET THE ESSENTIALS:

-prescription medications in original package with prescription attached
-over the counter medications such as aspirin, cold/allergy treatments, etc.
-sunscreen!
-laptops, cell phones, blackberries
-your government-issued personal identification
-appropriate clothing (it will be warm but we may have cool nights or rain)

INFORMATION COLLECTED ON THIS APPLICATION WILL BE USED SOLELY FOR THE PURPOSE OF REGISTERING PARTICIPANTS IN THE CARAVAN AND WILL NOT BE SHARED, SOLD OR TRADED WITH ANY OTHER PARTIES.

PLEASE BRING GOVERNMENT ISSUED IDENTIFICATION WITH YOU. NO ONE WILL BE PERMITTED TO BOARD THE BUSES WITHOUT PROPER IDENTIFICATION.