Anytown Delegate Application

You must complete all of the questions and send in your $25 registration fee to have a complete application.
Please send a check to:
NCCJ-ANYTOWN 1095 Day Hill Rd., Suite 100 Windsor, CT 06095.
Applications will not be processed until a confirmation of your $25 registration fee has been received.

If you cannot send the fee, contact Muneer at 860-683-1039 ext. 102 to make arrangements.

Muneer Panjwani
Director of Youth Programs
Phone: (860) 683-1039 x102 Fax: (860) 683-1409
Mpanjwani@nccjctwma.org

Please answer all questions.
Incomplete applications will not be processed.

Name

Address

City, State, Zip

Telephone Number
(xxx)xxx-xxxx

Cell/Other Number
(xxx)xxx-xxxx

Birthday
(mm/dd/yyyy)

E-Mail Address

Place of Birth

City
State
Country

T-Shirt Size

What school do you attend

What grade you will be in Next Year

Have you ever Attended ANYTOWN?

How did you hear about ANYTOWN

To insure diversity at ANYTOWN
we ask that you please check any of the following that apply to you.
It is important that you check at least one box in each section.
This information is confidential and will not be disclosed or used for any other purposes.

CLASS BACKGROUND

DISABILITIES

If yes please list

RACE

Please check all that apply
African American/Black	Latino/a
Asian/Pacific Islander	Middle Eastern
Indigenous/American Indian	White
Biracial/Multiracial	South Asian (Indian/Pakistani, etc)
Other

RELIGIOUS IDENTIFICATION
Please list specific religion in the category provided

SEX

SEXUAL ORIENTATION

DO YOU HAVE ANY DIETARY RESTRICTIONS, ALLERGIES OR SPECIAL NEEDS?

Other

Dietary Restrictions/Allergies
Special Needs

PLEASE ANSWER THE FOLLOWING QUESTIONS. FEEL FREE TO TYPE YOUR RESPONSES.
ALL 6 QUESTIONS MUST BE ANSWERED FOR THE APPLICATION TO BE ACCEPTED!
THERE ARE NO RIGHT OR WRONG ANSWERS!!!

1- What do you think ANYTOWN is about? What do you expect to do there?

2- What would you like to get out of your ANYTOWN experience?

3- What do you hope to add to the ANYTOWN experience? Why should you be chosen to attend?

4- In your own words, define the terms diversity and prejudice.

5- Have you ever attended any other programs that address diversity issues? Please share.

6- Do you take medications or have any dietary restrictions, allergies, mental health concerns or special needs?

If you have any questions about this application please contact:
Muneer Panjwani
Director of Youth Programs
Phone: (860) 683-1039 x102 Fax: (860) 683-1409
Mpanjwani@nccjctwma.org

Please make sure you answered all questions before you submit the application.
Incomplete applications will not be processed.

Parent/Guardian Name:

Date:

mm/dd/yy

IMPORTANT
By clicking the Submit button below you recognize that the young person named above is applying to attend the NCCJ ANYTOWN overnight program.