Black Votes Matter
Civic Engagement Academy 2023
A program designed to create connection between the past and the present, build leaders who understand and exercise their political power, and have pride in their history.
Program Dates:
Saturdays at 10am to 2pm: April 1st, 15th; May 6th, 20th, and June 3rd, 17th
Will you commit to attending all sessions?
Please Select
Yes
No
Student Information
Name
*
First Name
Last Name
Student Email
*
example@example.com
Birth Date
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pronouns
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Please Select
He/Him
She/Her
They/Them
Other (Please share)
Ethnicity
*
Please Select
Black/African American
Latino/Hispanic
Asian
Caucasian
Native American
Middle Eastern
Pacific Islander
Prefer Not to Answer
Grade Level
*
Please Select
9th
10th
11th
12th
Are you attending the 2023 BVM Black History Tour?
*
Please Select
Yes
No
If you answer 'YES', please move to 'Medical Infomation' section.
Parent/Guardian Information
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.
Parent/Guardian Residence Information
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Emergency Contact 1
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
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Emergency Contact Email
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Emergency Contact 2
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
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Emergency Contact Email
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Medical Information
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns, etc.
*
Accessibilty Needs
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Media Release
I hereby give permission for images of my child, captured during The Young History Detectives Program through video, photo and digital camera, to be used solely for the purposes of The House of Afros, Capes & Curls Inc. promotional material and publications, and waive any rights of compensation or ownership thereto.
Parent/Guardian Signature
*
Field Trip Authorization
give permission for my child (named above) to attend field trips associated with the Youth Civic Engagement Academy, as a part of Black Votes Matter Institute for Civic Engagement. I further give permission for Black Votes Matter Institute for Civic Engagement to transport my child on a public bus or van operated by Black Votes Matter or 4urban.org in a bus or van, driven by an individual authorized by Black Votes Matter Institute for Civic Engagement. I understand my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver and/or staff or volunteer.
Parent/Guardian Signature
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