ANYTOWN ALABAMA for Office Use Only
Anytown Alabama 2013
Delegate Application
Delegate Application
Anytown Alabama
June 2-8, 2013
Applicant Name: ______
We welcome applications from all students regardlessof race, creed, nationality, school, religion, gender,sexual orientation, immigration status, or ability.
Applications are also available at
Applicant Information-please write legibly:
Date:
Applicant Name: Preferred Name:
Address:
City:State:Zip:
Phone: E-mail:
Parent e-mail: Best way to contact you:
T-Shirt Size:Date of Birth:
School:Grade in 2012-13 school year:
To help our effort to have a diverse group of delegates, please be sure to fill out all sections below.
Gender:Racial/Ethnic Identity:
Religion/Faith Identity: Sexual Orientation:
Other groups with which I identify:
Dietary Restrictions: Languages Spoken:
Camp week: June 2-8, 2013
Will you be able to attend the entireweek of camp? Yes [ ] No [ ]
Have you ever been involved with NCCJ or YWCA Central Alabama (e.g. Heritage Panel, Make A Change Leadership Institute, volunteering)? Yes [ ] No [ ]
If yes, please specify:
How did you find out about Anytown Alabama?
Reference
Please have the confidential reference form (located at completed by an adult or Anytown Alum who is not related to you. Completed forms can be e-mailed, faxed, or mailed directly to the YWCA. Applications will not be considered without a completed reference form.
Personal Statement
What experiences, qualities, or ideas do you have that will make you a good contributor to Anytown Alabama? What do you expect to gain? Use the lines below or attach a sheet if you would prefer.
______
______
______
Dear Applicant and Parent(s):
Anytown Alabama is a significant program for both delegate and family. We encourage the delegate’s family to be part of this experience. Delegates and parents will be invited to both pre- and post-camp meetings. All applications must include a completed and signed Delegate Application and Reference Form to be considered. Please read over the following information:
Cost of Anytown:
Full and partial scholarships are available to delegates who need financial assistance. Students will not be prevented from attending Anytown because of their inability to pay. Neither staff nor delegates will know how much, if any, financial assistance is given to anyone. Thefee for Anytown is $400 which includes all meals, transportation, lodging, educational materials anda camp t-shirt. Send no money until notified of acceptance.
[ ] My child does not need a scholarship.
[ ] I would like to request a partial scholarship for my child. My family is able to pay $______for my child to attend camp.
[ ] I would like to request a full scholarship for my child.
Signatures- please write legibly:
Parent/Guardian Name Relationship to Applicant
Parent/Guardian Signature Date
Applicant Signature ______Date______
Return to: YWCA Central Alabama, 309 23rd St N, Birmingham, AL 35203 or fax (205) 521-9652 or save changes and e-mail to with ATTN: Anytown Alabama