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IncluCity Delegate Application

IncluCity Delegate Application

Welcome Future Delegates!

IncluCity 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 from Omaha metro area high schools enjoy the peaceful settings at Carol Joy Holling Retreat Center in 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 15-20 years old and is enrolled at the sponsoring school and is recruited by school staff.

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

IncluCity is facilitated at Camp Carol Joy Holling, located at 27416 Ranch Road, Ashland, Nebraska 68003, just North of Mahoney State Park.

For more information, please contact your high school's counseling department/ IncluCity Advisor or Colin McGrew, Inclusive Communities’ Senior Program Partner at

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 fully vaccinated against COVID-19 or will you be by the start date of the IncluCity you plan on attending? (i.e. have you received the necessary dose(s) of a COVID-19 specific vaccination?(Required)
Based on the guidelines above, are you willing to share your COVID-19 vaccination status with Inclusive Communities?*(Required)
Max. file size: 64 MB.
If you are willing to share your vaccination status/paperwork with Inclusive Communities, please upload your proof of vaccination here. This information will not be shared with anyone outside of Inclusive Communities and Partners. You can also email your vaccination materials to
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)
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.
For Parents - Liability Acknowledgment(Required)

Student Information

How would you like to be referred to at IncluCity and in IncluCity communication?
e.g. she/her, he/him, they/them etc.
Are you a minor (under 19 years)?(Required)
If you’re a minor under the age of 19, a parent and/or guardian’s permission is required to complete this form. Fields to enter parent information are located below.
You must be at least 15 years old to attend IncluCity.(Required)
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.
I agree that the information I have provided in this section is accurate and true.

School or Group

Schools and organizations contract with Inclusive Communities to attend IncluCity, our 4-day residential program. You must attend one of the following high schools to attend IncluCity during the 2022-2023 school year. Submission of this application does not guarantee you a spot with your high school's delegation. Please see your school's counseling department for information about program admissions.
I agree that the information I have provided in this section is accurate and true.

Program Information

Have you attended any of the following Inclusive Communities programming?(Required)
I agree that the information I have provided in this section is accurate and true.

Emergency Contact & Medical Information

General Information in case of emergency
Parental Consent(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. Please contact Carol Joy Holling if they can help you better prepare for your time with there during programming.

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.
When packing for IncluCity, please ensure you will have enough of your medication for the entire program, in its original package/bottle with dosage information. An adult staff member will dispense all needed medications to ensure proper dosage, confidentiality and security.
Medical Acknowledgement(Required)
I agree that the information I have provided in this section is accurate and true.
Emergency Release Agreement(Required)


Transportation Acknowledgement(Required)
In order to participate in IncluCity, I am aware I will be in programming from Friday to Monday. Inclusive Communities will provide transportation to pick me up at my high school on Friday, and return me back to my high school on Monday by 5:00PM. I can receive specific information and transportation schedule from my IncluCity Advisor. I am aware that I will need to coordinate a ride home from the drop-off location upon my return on Monday.

Media Release

Media Waiver(Required)
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 given to all of the IncluCity program participants and staff and may be circulated by Inclusive Communities for programmatic and funding purposes, and I consent to the Participant's inclusion in such group photograph. *Boxes must be marked and parental signature for student to participate in media releases.

IncluCity Participant & Guardian Agreement

Participant Agreement(Required)
Participant Agreement

As a participant in the IncluCity program of Inclusive Communities, I recognize my responsibility to my family, my school, my sponsor, 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, pagers, mp3 players, tablets, 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 Carol Joy Holling. In case of an emergency, my family may call Inclusive Communities staff who will relay the message to me when I am available. 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 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.

Parent/Guardian Agreement(Required)
Parent/Guardian Agreement

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