Anytown Delegate General Information Application 2024

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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 live in or attend school in North Carolina's Piedmont Triad region.

To complete this application, you will need the name, contact information (phone and email), title, and school or organization of a community member willing to support 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 2024 session of AnytownI am applying for the July 2024 session of AnytownI can attend either session

First Name

Last Name

Who is filling out this application?

StudentParent/Guardian Other

If "other" for the above question, please tell us how the person filling out the application is related to the student.

What does the student preferred to be called?

Pronouns

Grade you will enter in fall of 2024

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

Best Email to reach you at

Cell Area Code

Cell Phone Number

Home Area Code

Home Phone Number

By checking the text opt-in box you are agreeing to receive periodic SMS and/or MMS message from this organization. Message and data rates may apply. Text HELP for more information. Text STOP to stop receiving messages

If you chose "other", please tell us your preferred form of communication?

T-Shirt Size

Next page: Parent/Guardian information

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Community Member Support

Anytown challenges students to discuss their experiences with and attitudes about human relations issues. That's why NCCJ asks each student applicant to get support from a community member, such as a teacher, counselor, principal, supervisor, or faith leader. By supporting the student application, the community member is agreeing that the student is physically, emotionally, and mentally capable of participating in Anytown.

Please provide the name of a community member that we can contact for support of your application.

Supporter First Name

Supporter Last Name

School/Agency

Title

Supporter Area Code

Supporter Phone Number

Supporter Email

Next page: Tuition, fees and tuition assistance

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Tuition, Fees & Tuition Assistance

Cost of Attending

The full cost of attending Anytown is $650.
$50 of the $650 is a non-refundable registration fee.
If you register and pay in full by April 15, we will waive your $50 non-refundable registration fee.

Tuition Refunds from Cancellation/Early Departure

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 due to illness.
To receive a refund, submit your request to Alison Whitman Jones (ajones@nccjtriad.org) before August 1^st.
No refunds will be given for a delegate who leaves a session early.

Tuition Assistance:

NCCJ works hard to ensure Anytown delegates include a diverse population. This includes socio-economic diversity. Generous, need-based tuition assistance is available to all applicants. Please do not let your need for assistance discourage you from applying for Anytown.
NCCJ will do our best to work with your family to cover the fees that you cannot. We ask that you please only request what you truly need so that we can provide aid to everyone who needs assistance.
Please indicate below whether you are applying for tuition assistance and how much of the full cost of attending Anytown ($650) you can pay.
All information provided will be kept confidential.
All tuition assistance applicants will receive a statement from NCCJ indicating whether their request for tuition assistance has been accepted or declined.

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

Annual household income

Number of people in household

If there are other compelling circumstances or important information that you feel would give us a more accurate and complete picture of your financial situation, please provide this information below.

In addition to paying my child's tuition, I would like to help NCCJ cover some or all of the actual costs of Anytown 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 NCCJ's Anytown 2023 residential program.

Parent/Guardian Signature

Parent/Guardian Signature Date