All In Summit 2025 Chaperone Form

All In Summit Chaperone Form

Space is limited for chaperones at the All In Summit this year. Chaperones will all be assigned on a first come-first served basis. Chaperone accommodations will be dorm style - 2 chaperones per room, with a bunkbed and jack-n-jill bathroom to share with 2 other chaperones. No more than 1 chaperone per student. All chaperones must have a student coming from their Region to qualify to attend. All chaperones owe a registration fee of $375 that can be submitted by check or via the Junior Civitan website on the "donate" tab.

Legal Name (as reflected on your I.D.)

Chaperone Preferred Name

Phone

Date of Birth?

Gender?

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What Region are you representing?

How will you be travelling to the event?

Air

Auto

If air, are you interested in booking your travel together with a Junior participant?

Yes

No, I will book my travel on my own

*Chaperones are responsible for covering the cost of their own travel accommodations, however Civitan can arrange to have your accommodations booked with our travel agent.

If so, what is your preferred airport?

If so, what is your second choice of airport?

Do you have a known traveler number? If, so please submit below.

Health Insurance Provider

Health Insurance Policy #

Health Insurance Group Number

Roommate Preference:

We will try our best to accommodate to your roommate of choice.

Do you have a disabilty that would prevent you from sleeping on a top bunk?

Please explain any medical information of which we should be made aware. List all allergies to medication, food, animals, etc.

Please list any dietary restrictions (Example: vegetarian, vegan, gluten-free, etc.)

Please include any additional information you would like Civitan International staff to know.

Emergency Contact Name

Emergency Contact Relationship

Example: parent, guardian, spouse, child, etc.

Emergency Contact Phone

Emergency Contact Email