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ABOUT C.H.A.N.G.E.
THE C.H.A.N.G.E MANTRA
Founders' Passion
Programs
Volunteer
Contact Us/inquiries
Home
ABOUT C.H.A.N.G.E.
THE C.H.A.N.G.E MANTRA
Founders' Passion
Programs
Volunteer
Contact Us/inquiries
Program Application (June 26, 27 & 28, 2017) Elizabeth City, NC
REGISTRATION DEADLINE:
Monday, June 12, 2017 (New Deadline)
REGISTRATION FEE DEADLINE: Friday, June 16, 2017
Registration Fee is $25.00 (may be paid via check or via PayPal)
Payment may be sent via PayPal.com to
[email protected]
.
*
Indicates required field
Student's Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Current School
*
Grade for Upcoming 2017-2018 School Year (Rising Grade)
*
Age
*
T-Shirt Size
*
Please indicate your t-shirt size.
Parent/Guardian Information
Parent's/Guardian's Name
*
Parent's/Guardian's Phone Number
*
Parent's/Guardian's Email
*
If you do not have an e-mail address, please input the following:
[email protected]
Please list other activities student is involved in:
*
What is the best way to reach you (Check All that Apply)
*
E-mail
Phone
Text
Check All that Apply
Adult Recommendation
(Family Member, Family Friend, Community Leader, etc)
Name
*
Adult Recommendation can be a Family Member, Community Leader, etc.
Position/Relationship to student
*
Why do you recommend this student for this program?
*
Does the student display any behavioral issues that may present a challenge while working in a team environment during the workshop?
*
No
Yes, Please Explain Below
Please explain any behavioral issues here.
*
If the answer is no, please write N/A. If the answer is yes, please explain the behavioral issue(s) here.
What are some focus areas that woud benefit this student?
*
All Applicants Must Complete This Section
My goals are:
*
List your hopes, dreams, desires, or even your summer or academic goals. We just want to know more about you!
I want to improve in the following areas. Check all that apply.
*
Communication
Confidence/Self-Esteem
Decision Making/Problem Solving
Focus/Self-Discipline
Motivation
Public Speaking
Teamwork
Time Management
Money Management
Please tell us about yourself and why you are interested in the CAMP EMPOWER 2017 Summer Program.
*
We want to know more about you so we can tailor the workshop, so come on tell us a little about YOU!
PAYMENT INFORMATION
Checks are payable to CHANGE Enterprises, Inc
PayPal payments are to
[email protected]
Program Point of Contacts:
[email protected]
Dr. Jametta Davis, 703-899-0482
Shavonta Green-Floyd, 703-798-6303
Melba Smith, 252-335-3985
TO SUBMIT YOUR APPLICATION, PLEASE PRESS "SUBMIT" BUTTON BELOW.
If you make an error or need to amend the application, please e-mail us at
[email protected]
.
Submit
