Black To Our Roots 2012 - 2013 Youth Application Survey

1. Thank you for applying to participate in the 2012-2013 Black To Our Roots program! We will begin selecting youth for the program beginning in May 2012. The program will start in August 2012. In the meantime, continue to get updates on all of HABESHA's activities at www.habeshainc.org.

Thank you for applying to participate in the 2012-2013 Black To Our Roots program! We will begin selecting youth for the program beginning in May 2012. The program will start in August 2012. In the meantime, continue to get updates on all of HABESHA's activities at www.habeshainc.org. Name:
Birthdate:
Address:
City/Town:
State:
ZIP:
School
Email Address:

2. PARENT INFORMATION

PARENT INFORMATION Name:
Address:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

3. EMERGENCY CONTACT INFORMATION: In case of emergency when we can’t reach parents/guardians we need information of a family or friend we may contact.

EMERGENCY CONTACT INFORMATION: In case of emergency when we can’t reach parents/guardians we need information of a family or friend we may contact. Name:
Relationship to youth
Address:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

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4. Do you have health insurance? If so, who is the provider.

Do you have health insurance? If so, who is the provider.

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5. Are their any allergies/medical conditions we should be aware of? If so, please explain.

Are their any allergies/medical conditions we should be aware of? If so, please explain.

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6. Please answer the following questions in a 500-word essay.

1.Who are you? (Please introduce yourself including name, school, age,
interests, hobbies, personality, and personal goals.)

2. What do you know about African history and culture?

3. Why do you want to participate in the Black To Our Roots Program?

4. What do you expect to learn from the Black To Our Roots Program?

Please answer the following questions in a 500-word essay. 1.Who are you? (Please introduce yourself including name, school, age, interests, hobbies, personality, and personal goals.) 2. What do you know about African history and culture? 3. Why do you want to participate in the Black To Our Roots Program? 4. What do you expect to learn from the Black To Our Roots Program?

Black To Our Roots 2012 - 2013 Youth ApplicationExit this survey

1. Thank you for applying to participate in the 2012-2013 Black To Our Roots program! We will begin selecting youth for the program beginning in May 2012. The program will start in August 2012. In the meantime, continue to get updates on all of HABESHA's activities at www.habeshainc.org.

2. PARENT INFORMATION

3. EMERGENCY CONTACT INFORMATION: In case of emergency when we can’t reach parents/guardians we need information of a family or friend we may contact.

*4. Do you have health insurance? If so, who is the provider.

*5. Are their any allergies/medical conditions we should be aware of? If so, please explain.

Black To Our Roots 2012 - 2013 Youth Application
Exit this survey

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4. Do you have health insurance? If so, who is the provider.

*
5. Are their any allergies/medical conditions we should be aware of? If so, please explain.