Join us in St. Simon Island for our 30th Annual Black Youth Leadership Development Institute!

Harambee House, Inc. hosts its 30th annual event, July 29 — August 2, 2019.  We bring inner-city teenagers and young adults to the Epworth-By-The-Sea resort and retreat for five days of intense workshops and seminars on leadership and community activism.  This is an opportunity for our youth to explore and identify the issues they find most pressing.  They will then develop ways to change and improve their lives.  The age range for the Institute is 13 — 18 years.

Sign up on the form below.  Join these young men and women as chaperones and participate in this life-changing event!

BYLDI Participant Application

Participant Information

Name *

First

Last

Birth Date *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Age *

Organization

Address

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City

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Zip Code

Cell Phone

Home Phone

Parent/Legal Guardian Name *

First

Last

Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Cell Phone

Home Phone

Work Phone

School Information

School Name *

Address *

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Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Important Information

Do You Have A Passport? *

• Yes
• No

Are All of Your Immunization Shots Up To Date? *

• Yes
• No

Your Community

My Community is: *

• Urban (in the city)
• Suburban (just outside the city)
• Rural (at least 25 miles or more outside the city)

What Are The Best Things About Your Community? *

What Are The Worst Things About Your Community? *

Is Your School: *

• Public
• Private
• Christian
• Catholic
• Muslim
• Charter
• Home-School
• Other (please describe below)

What Are Three Things You Like Best About Your School? *

What Are Three Things You Would Change About Your School? *

What Do You Hope To Obtain From Our Leadership Development Institute? (Include Two Skills That You Would Like To Learn) *

Emergency Contact

Name of Adult / Community Mentor / Chaperon: *

First

Last

Relationship To Participant *

• Parent
• Guardian
• Sibling
• Relative
• Neighbor
• Other (describe below)

Cell Phone

Home Phone

Work Phone

Medical Information

Name of Doctor / Clinic *

First

Last

Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Contact Number *

Medical Insurance *

Do You Have Any Disabilities? *

• Yes
• No

If Yes, Please Explain:

Are You Currently Taking Any Medication? *

• Yes
• No

If Yes, Please Explain

Were You Ever Diagnosed With A Mental Health Issue? (i.e, Depression, Bi-Polar, Anxiety Attacks, etc.) *

• Yes
• No

If Yes, Please Explain

Do You Have Any Food Allergies? *

• Yes
• No

If Yes, Please Explain

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