STARR - Students Talking About Race and Racism Application 2021

STARR logo in NCCJ colors
STARR: Students Talking About Race + Racism is a 3-day, non-residential NCCJ program for students interested in learning about the current and past manifestations of race and racism in our country. Click here to learn more about STARR.

STARR will take place June 10-12, 2021 as a hybrid (part in-person, part physically-distanced) program. Days 1 and 3 (
June 10 and June 12) are in-person and day 2 (June 11) is virtual.
Applicant Information













(Ex: man, woman, transgender man, transgender woman, etc.)









Parent/Guardian Information
Parent /Guardian #1










Parent /Guardian #2










Demographic Information
To ensure diversity at STARR, we ask that you please check any/all of the following that apply to you:  (This information is confidential and will be viewed by NCCJ staff only.  It will not be used or disclosed for any other purposes.)





Tuition, Fees & Tuition Assistance

STARR Tuition is $100.  Generous need-based tuition assistance is available.


We strongly encourage you to confirm your participation as early as possible in order to ensure there is still a space available for you.  Participation is limited to 25 students, however, if there is an overwhelming demand from applicants, NCCJ may offer a 2nd session.

ex: $25, $100
ex: $25, $100
ex: $25, $100

We accept cash, checks, money orders and all major credit cards. For credit card payments, please call our office or click here to pay online.


By signing below, I verify that I have thoroughly read the information listed in the tuition, fees and tuition assistance section of this application. I give my permission for the young person named above to apply as a delegate for the NCCJ of the Piedmont Triad STARR program.



Health History and Medical Release Form

All medical information will be kept strictly confidential.


This section should be completed by a parent or guardian.

Auxiliary Emergency Contact 1 Information











Medical Conditions








Dietary Restrictions
Food cannot be prepared to order. However, the we will do our best to accomodate dietary requests.  (We do not have a kosher or halal kitchen.)


Parent/Guardian Authorization
This health history is correct and complete as far as I know, and my child/the child in my care has permission to participate in the program activities except as noted.  I also understand that NCCJ of the Piedmont Triad, Inc., its officers, board members, volunteers, agents, employees and licensees cannot be held liable for any health complications or problems that resulted from or were caused by my child's/the child in my care's negligent regard for his/her own health and safety.

Delegate Agreement to Abide by Health Restrictions
I understand and agree to abide by the restrictions placed on my activities during this program.  I agree not to infringe on the safety of or knowingly cause bodily harm to the others in attendance at STARR.  I also understand that NCCJ of the Piedmont Triad, Inc., its officers, board members, volunteers, agents, employees and licensees cannot be held liable for any health complications or problems that resulted from or were caused by my negligent regard for my own health and safety.


Photo Release
I am the parent/legal guardian of this applicant who will be participating in activities sponsored by the NCCJ of the Piedmont Triad, Inc. including STARR.  I understand that my child/the child in my care, alone or with other participants and/or NCCJ of the Piedmont Triad, Inc. staff, volunteers or representatives, may be interviewed, photographed, recorded on film, audio tape, video, or other visual and sound computerized, telephonic, voice-mail or tape media ("photographs and/or sound/image recordings") and/or may provide written or oral statements to NCCJ of the Piedmont Triad, Inc. and/or others approved by NCCJ of the Piedmont Triad, Inc.

I hereby consent to the foregoing and grant permission, without reservation, to NCCJ of the Piedmont Triad, Inc. and/or those approved by NCCJ of the Piedmont Triad, Inc. to generate, prepare, advertise, describe, and/or publicize NCCJ of the Piedmont Triad, Inc. and its work, good will, public education and/or fundraising activities, disseminate, otherwise use and comment upon the photographs and/or sound/image recordings as they may determine, without review by me or my child/the child in my care and without financial or other obligation of any nature to me or my child/the child in my care.  I consent that my child/the child in my care may be identified by name, age, race, school of attendance, city of residence, or program of participation as these companies and/or those approved by these companies may determine.  Uses may include, but are not limited to, promotional videos, fundraising appeals, website content, and news coverage.

I release NCCJ of the Piedmont Triad, Inc., its officers, Board of Directors, volunteers, agents, employees and licensees from all claims that I or my child/the child in my care may have, or might have, for any cause of action arising out of the taking and/or use of the photographs and/or sound/image recordings as set forth herein.  This consent and release shall continue in effect, without a limitation of time.