2026 IncluCity Application - Inclusive Communities

IncluCity Full Application 2026

This application must be completed by both the applicant and their parent/guardian to be submitted. There is a save and continue option if you need more time to complete the full application.

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Welcome Future Delegates!

IncluCity Leadership Camp scheduled for April 10-13, 2026, is a cutting edge, time-tested, human relations program for high school students, designed to empower youth to create respectful and just communities. For four days during the school year, young adults ages 14-19 from Nebraska, Iowa and South Dakota area high schools enjoy the peaceful settings of Ashland, Nebraska.

Our time-tested curriculum is designed to engage students in productive dialogue around issues of race, class, faith, ability, gender, sexual orientation, age and appearance. Delegates (students) learn the impact of prejudice on their own lives as well as the lives of others, and define for themselves their role and responsibility in creating inclusive and respectful communities.

IncluCity is a place to:

– Break down barriers of prejudice and oppression by enhancing diversity awareness

– Learn about cultures, faiths, ethnicities, etc.

– Enhance dialogue and other essential skills within safe and comfortable settings

– Build and live in an inclusive community

– Explore who we are in relationship to each other and the environments that surround us

– Learn about your responsibility as a leader to create more inclusive communities

– Build cross-cultural lasting relationships

Who can attend IncluCity?

– Any young adult age 14-19 years old who has consent to attend from a Parent/Guardian.

– Applicants should be emotionally prepared to discuss tough issues such as: racism, gender roles, faith, class, sexism, culture, and more.

IncluCity is facilitated in Ashland, Nebraska.

For more information, please contact Cammy Watkins at Cammy@inclusive-communities.org

COVID-19 Policy

Inclusive Communities recommends that all participants at IncluCity be fully vaccinated against COVID-19, however, vaccinations will not be required to attend. In order to keep IncluCity COVID-19 free and avoid any camp shutdowns we are asking ALL delegates and attendees of IncluCity to provide proof of a negative COVID-19 test.

Are you willing to provide a negative COVID-19 test within the specific time window set forth by Inclusive Communities before the start of your IncluCity Session?(Required)

Yes

Proof of a negative COVID-19 test will be required by everyone attending IncluCity. Inclusive Communities will provide a COVID-19 test to all participants, free of charge.

Student Information

First and Last Name(Required)

Preferred Name(Required)

How would you like to be referred to at IncluCity and in IncluCity communication?

Pronouns

e.g. she/her, he/him, they/them etc.

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Birthdate(Required)

T-Shirt Size

Are you a minor (under 18 years)?(Required)

Yes

If you’re a minor under the age of 18, a parent and/or guardian’s permission is required to complete this form. Parent/Guardian section is below.

You must be at least 14 years old by April 10, 2026 to attend IncluCity.(Required)

I am at least 14 years old

Primary Phone Number(Required)

Secondary Phone Number

Acknowledgement(Required)

I agree

I agree that the information I have provided in this section is accurate and true.

Demographic Information

To ensure specific perspectives in Inclusive Communities programs, please supply the following information about your identities.

Ethnicity/Race(Required)

Spirituality/Religion(Required)

Gender Identity(Required)

School(Required)

Please list the full name of the school you attend. If you attend Home School please indicate what Home School program you are part of or if it is Family based.

What grade are you in?(Required)

Anticipated Graduation Date(Required)

Other Personal Identity

Interests & Special Skills

Program Information

How were you referred to or learn about IncluCity?

Outside of your family members or close non-family friends are there any trusted adults in your life that support you? If No, write No. If yes, please share a brief story about how this individual(s) have impacted your life.

Why do you want to attend IncluCity?

Have you attended any of the following Inclusive Communities programming?(Required)

IncluCity

Omaha Table Talk

ACTion Workshop

Recruitment Booth

None, I have not attended Inclusive Communities programming before

Acknowledgement(Required)

I agree

I agree that the information I have provided in this section is accurate and true.

Participant Agreement(Required)

I agree to the Participant Terms of Agreement

As a participant in the IncluCity program of Inclusive Communities, I recognize my responsibility to my family, my school, my community and myself. I agree to be present for the entire IncluCity program session and that my behavior will be respectful and responsible throughout the program. I understand and agree to each of the following conditions:

1. I understand that IncluCity is an “unplugged” weekend, where I cannot use cell phones, smart watches, tablets, laptops, gaming systems, etc. These items will be taken on the first day, kept in a safe, secure place, and returned to me prior to departure, if brought to IncluCity. In case of an emergency, my family may call Inclusive Communities staff who will relay the message to me as soon as possible.

2. I must remain at the IncluCity program site until the IncluCity program is over and may not leave the program site on my own for any reason.

3. I am not allowed to engage in any activities while I am at the IncluCity program site that will endanger myself, other participants or cause damage to the site facilities.

4. I understand that I may not use Inclusive Communities programming or materials outside of the IncluCity program with express permission from the Inclusive Communities Executive Director.

Signature

Student/Participant Signature

Parent Guardian Section

The following sections must be completed by a Parent or Guardian if the applicant is under 19 years of age.

Name of Parent/Guardian(Required)

Relation to applicant

Parent/Guardian Phone Number(Required)

Emergency Contact Secondary Phone Number

Parent/Guardian Email(Required)

Secondary Emergency Contact

Secondary Emergency Contact Phone Number

Relation to applicant

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Name of Primary Care Physician

Does the applicant require any language or communication accommodations? If No, write No. If Yes, please list which the type of accommodation needed.(Required)

Inclusive Communities is committed to language accessibility upon request we will engage interpreters for programming portions of camp.

Does the applicant require any physical accommodations in order to engage fully at IncluCity? If No, just write "No', if Yes, please explain:(Required)

Please list any dietary accommodations that we should be aware of, if none write None, otherwise please list below.(Required)

The Food Services staff at Carol Joy Holling Center aims to provide creative and delicious dining experiences for all guests, and wants to be supportive of those unable to enjoy some of any offerings due to certain food intolerances or allergies. In those cases, CJH asks guests to be sure to use discretion in deciding what food choices to make at each meal. Even though CJH cannot guarantee that specific ingredients or allergens are not present (CJH does not have separate kitchens to prepare allergen-free items), CJH wants to do their best to accommodate your needs. So, at your request, CJH is happy to always have the following replacement items available for you:

• Plain Grilled Chicken Breast

• Gluten Free Roll

• Vegetarian Burger on a Bun

• Soy Milk.

Many times guests with specific allergies or dietary needs choose to bring their own special food items to supplement what CJH serves. Of course, CJH supports those decisions and are happy to provide refrigerated space to store those items for you.

Typically, CJH’s menus are planned one week ahead. If you have concerns about dietary restrictions please contact Cammy.

Inclusive Communities and its hosts may not be able to accommodate all needs. Please call Inclusive Communities if you have concerns regarding what our campsite host is limited to. Personal supplements should be brought, and we are happy to assist you with its specific requirements.

Please list all allergies and allergic reactions to foods, medication, or other substances.(Required)

Please list any medical conditions the IncluCity Medical Team should be aware of.(Required)

IncluCity has a medical team which includes 2 Licensed Mental Health Practitioners and one Nurse Practitioner. A member of the medical team will follow up with you regarding information listed in this section.

Please list any medications you are taking.(Required)

When packing for IncluCity, please ensure you will have enough of your medication(s) for the entire program, in its original package/bottle with dosage information. The IncluCity Nurse will dispense all needed medications to ensure proper dosage, confidentiality and security.

Transportation

Transportation Acknowledgement(Required)

I have read and understood this statement

In order to participant in IncluCity, I am aware the participate will be in programming from Friday to Monday. Inclusive Communities will provide transportation to pick participant up at the designated location on Friday, and return back to the designated location on Monday. Parent/Guardian will receive specific information and transportation schedule from Inclusive Communities staff. I am aware that I will need to coordinate with participant for the drop-off and pickup at designated location on Friday and Monday.

Media Release

Media Waiver(Required)

Yes, I DO consent and agree to the media release terms

No, I DO NOT consent or agree to the media release terms

I am the parent or guardian of the above-named Participant, who will be participating in the IncluCity program of Inclusive Communities. I understand that the Participant, while participating in the IncluCity program, along with other participants in the IncluCity program and IncluCity staff, volunteers, and representatives of Inclusive Communities, may be interviewed, may provide written or oral statements, and may be photographed and recorded on film, audiotape, videotape, or other visual, sound, electronic, telephonic, voice-mail, or taped media (“Photographs and Sound/Image Recordings”) by Inclusive Communities and others approved by Inclusive Communities. I hereby consent to the participation of the Participant in such interviews and the inclusion of the Participant in the Photographs and Sound/Image Recordings and grant permission, without reservation, to Inclusive Communities and others approved by Inclusive Communities to describe or publicize Inclusive Communities and its program, fund-raising, and other activities through the use of, and otherwise disseminate, use, and comment upon, such interviews, written or oral statements, and Photographs and Sound/Image Recordings of the Participant as Inclusive Communities and others approved by Inclusive Communities may determine, without review by me or the Participant and without financial or other obligation of any kind to me or the Participant. I release Inclusive Communities and its officers, directors, volunteers, agents, employees, licensees, and assignees from any and all claims that I or the Participant at any time may have for any cause of action arising out of the making or use of the interviews, written or oral statements, and Photographs and Sound/Image Recordings of the Participant. If neither of the boxes below is marked, then I DO consent to the media release terms set forth above.

I am aware that all IncluCity program participants will be included in a group photograph which will be accessible to all of the IncluCity program participants and staff and may be circulated by other participants or Inclusive Communities for programmatic and funding purposes. I consent to the Participant’s inclusion in such group photograph.

*Boxes must be marked and parental signature below is required for student to participate in media releases.

IncluCity Guardian Agreement

Parent/Guardian Agreement

As parent/guardian, I agree all information indicated in this form is true and I consent to participation.

Signature(Required)

Parent/Guardian Signature