Participant Referral UPDATED

Thank you for your interest in the uBuntoo Leadership Institute! Completed and processed forms  gains the participant access to a year’s membership to the National Council of Negro Women. Our program provides opportunities for community leadership, entrepreneurial skills, social development, digital citizenship, and cultural enrichment.

Upon receipt of your application, our staff will review and determine eligibility, follow up with any questions and will inform you about the status of your teen’s application.

 

Note: If the applicant is a “new” 17 years old, they may be considered for eligibility by completing and signing  their own registration form.

    Participant Referral Form




    Youth and Family Information


    Teen's Information:


































    Parent/Guardian Information:


































    Emergency Contacts, First Aid, Medical Care Consent


    Emergency Contacts
































    Child's Pediatrician or Source of Health Care:










    Medical Information








    First Aid Medical Care Consent (Enter Name as Signature)






    Media Release




    Parent/Guardian Signature