Black To Our Roots 2012 - 2013 Youth Application (Baltimore)

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* 1. Thank you for applying to participate in the 2013 -2014 Black To Our Roots program! Applications are due Friday, December 21, 2012, however, applicants are encouraged to submit applications as early as possible. Selected participants will be notified by the first week of January 2013. In the meantime, continue to get updates on all of HABESHA's activities at www.habeshabmore.org.

Name:

Birthdate:

Address:

City/Town:

State:

ZIP:

School

Email Address:

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* 2. PARENT INFORMATION

Name:

Address:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

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* 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.

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.

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* 5. 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. Why do you want to participate in the Black To Our Roots Program and travel to Africa?

3. What do you expect to learn from the Black To Our Roots experience?

4. Why should you be selected to participate in the Black to Our Roots program?