Anytown Delegate Application 2022

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Anytown is NCCJ's flagship youth leadership and human relations summer camp. Click here to learn more about Anytown.

To be eligible to attend Anytown as a delegate, you must be a rising high school sophomore, junior or senior and you must attend a school in Guilford County or live in Guilford County.

To complete this application, you will need phone numbers for alternate emergency contacts, contact information, policy number and group number for your health insurance (if applicable), and the name, contact information (phone and email), title, and school or organization of a community member willing to endorse your application.

At any time you can save your progress (check the box at the top of the form) and come back to finish and submit it later. Should you need assistance completing this application please contact Alison Whitman Jones at ajones@nccjtriad.org or (336) 272-0359 x 130.

Applicant Information

Please select the session of Anytown you wish to attend

I am applying for the June 19 - 24, 2022 session of AnytownI am applying for the July 17 - 22, 2022 session of AnytownI can attend either session

First Name

Last Name

Grade you will enter in fall of 2022

Birth Month

Birth Day

Birth Year

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Gender

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

High School

If "Other" for High School, please list here:

Graduation year

Email

Cell Area Code

Cell Phone Number

Home Area Code

Home Phone Number

T-Shirt Size

Next page: Parent/Guardian information

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Parent/Guardian Information

Parent /Guardian #1

First Name

Last Name

Email

Employer

Work Area Code

Work Phone Number

Cell Area Code

Cell Phone Number

Home Area Code

Home Phone Number

Parent /Guardian #2

First Name

Last Name

Email

Employer

Work Area Code

Work Phone Number

Cell Area Code

Cell Phone Number

Home Area Code

Home Phone Number

Next Page: Demographic information:

To ensure diversity at Anytown, 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.)

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Community Member Endorsement

We ask that each applicant obtain an endorsement from a teacher, counselor, principal, supervisor or clergy. By endorsing the applicant, it is agreed that the applicant is physically, emotionally and mentally capable of participating in Anytown, which challenges students to discuss their experiences with and attitudes about human relations issues.

Please provide the name of a community member that we can contact for an endorsement.

Endorser First Name

Endorser Last Name

School/Agency

Title

Endorser Area Code

Endorser Phone Number

Endorser Email

Next page: Tuition, fees and tuition assistance

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Tuition, Fees & Tuition Assistance

A $50 NON-REFUNDABLE REGISTRATION FEE IS REQUIRED TO PROCESS YOUR APPLICATION. If NCCJ does not accept your application, your $50 registration fee will be refunded.

In addition to the registration fee, camp tuition is $600. (The actual cost of Anytown is $1,200 per delegate. Thanks to the generosity of our donors we are able to offer tuition at a reduced rate of $600.)

Generous, need-based tuition assistance is available.
A 50% refund of tuition will be made upon written request when a cancellation is made at least three weeks before a session.
A full refund of tuition will be made if cancellation is because of a delegate's illness. A doctor's statement of the delegate's inability to participate must be submitted with the parent's written request. To receive a refund, submit your request before August 1.
No refund will be given for campers who leave sessions early.

Application deadlines:

There is no deadline to apply for Anytown. While we encourage you to apply as soon as possible, we will accept applications Anytown 2022 is completely full.

However, we strongly encourage you to apply early so that you can A) reserve your spot at ANYTOWN and B) enjoy these "early bird" registration perks:

If you register and pay in full by April 15, we’ll waive your $50 registration fee.

Tuition assistance deadlines:

Generous need-based tuition assistance is available to all applicants. (Note: these dates only apply if you are requesting tuition assistance.)

April 15: Priority deadline for tuition assistance.
May 20: Second round deadline for tuition assistance.

All information provided will be kept confidential. Please remember that the total tuition and registration fee for Anytown 2022 is $650.

Please select one of the following statements regarding tuition assistance:

I AM NOT applying for tuition assistance.I AM applying for tuition assistance.

Of the $650 cost of Anytown, I am able to pay:

ex: $25, $100

I would like to request tuition assistance in the amount of:

ex: $25, $100

In addition to paying my child's tuition, I would like to help NCCJ cover some or all of the actual costs of Anytown($1,200 per delegate) by making an additional contribution of:

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 Anytown 2022 residential program.

Parent/Guardian Signature

Parent/Guardian Signature Date

Next page: Health history and medical information

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Dietary Restrictions

Food cannot be prepared to order. However, the Blowing Rock Conference Center staff accomodate dietary requests to the best of their ability. (They do not have a kosher or halal kitchen.)

If "Other" is checked above, please explain: