Anytown Delegate Application 2023

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Anytown
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














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









Next page:  Parent/Guardian information

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Parent/Guardian Information
Parent /Guardian #1










Parent /Guardian #2










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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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.)











Next Page:  Community member endorsement

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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.








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 2023 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:

Generous need-based tuition assistance is available to all applicants.

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

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 NCCJ's Anytown 2023 residential program.



Next page:  Health history and medical information

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Health History and Medical Release Form

All medical information will be kept strictly confidential.


This section should be completed by a parent or guardian.

Delegate Information













(Ex: man, woman, transgender man, transgender woman, etc.)
Parent /Guardian #1




Street Address Line 2








Parent /Guardian #2




Street Address Line 2








Auxiliary Emergency Contact 1 Information




Auxiliary Emergency Contact 2 Information




COVID-19 Information
Delegates must provide proof of vaccination, recovery from COVID-19, or negative COVID test results prior to boarding the bus to Anytown.


I acknowledge and confirm that all information provided in the COVID-19 section of this application is true and complete to the best of my knowledge and agree to comply with all COVID related requirements for Anytown.


























Over the Counter Medication Administration

Immunizations

Medical Conditions








Health Insurance












Permission to Provide Necessary Treatment or Emergency Care
In the event of an accident or illness that requires emergency medical care, I hereby give permission to the attending (licensed) medical personnel to order such medical attention as may be deemed necessary for the health and safety of my child/the child in my care.  In the event that I cannot be immediately reached, I hereby give permission to the nearest qualified medical facility to secure and administer treatment, including hospitalization, to my child/the child in my care.


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 Anytown.  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.


Next page:  Dietary restrictions

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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.)