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?
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Student Information
Name
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Student Email
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Birth Date
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Day
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Address
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Pronouns
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He/Him
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Ethnicity
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Black/African American
Latino/Hispanic
Asian
Caucasian
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Grade Level
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9th
10th
11th
12th
Are you attending the 2023 BVM Black History Tour?
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If you answer 'YES', please move to 'Medical Infomation' section.
Parent/Guardian Information
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Parent/Guardian Email
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Parent/Guardian Name
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Parent/Guardian Email
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Parent/Guardian Phone Number
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Parent/Guardian Residence Information
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Emergency Contact 1
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Emergency Contact 2
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Medical Information
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns, etc.
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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
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Field Trip Authorization
I give permission for my child (named above) to attend field trips associated with The Young History Detectives Program, as a part of The House of Afros, Capes & Curls. I further give permission for The House of Afros, Capes & Curls 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 The House of Afros, Capes & Curls, Inc. 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.
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