2027 Michigan and Flint HBCU Tour Chaperone Interest Form
16th Annual Dr. Joyce M. Dixon HBCU Tour | March 29-April 2, 2027. Planned visits: Hampton University, Norfolk State University, North Carolina Central University, North Carolina A&T State University and Winston-Salem State University, plus a full day in Myrtle Beach, South Carolina. This form records your interest in serving as a chaperone; selection and travel arrangements will be confirmed by The Motivational Foundation.
Name
*
First Name
Last Name
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
T-Shirt Size
*
Please Select
XS
Small
Medium
Large
X-Large
XX-Large
XXX-Large
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Emergency Contact
*
Preferred Method of Communication
*
Text Message
Email
Name of Current Employer
*
Address of Current Employer
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Briefly tell us about yourself and why you are interested in serving as a chaperone for the 2027 Michigan and Flint HBCU Tour.
*
Do you have any physical limitations, health concerns or restrictions we may need to know about?
*
Yes
No
If selected, the Motivational Foundation requires chaperones who are not employed at a partnering school to undergo a background check with one of our preferred vendors. Chaperones are responsible for the cost of the background check.
*
I agree
If selected, I understand that I may need to provide 2-3 professional references.
*
I agree
Submit
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