Metrotown Application (New Form)

MetroTown Delegate Application 2018

MetroTown is a selective leadership and antiprejudice program for youth from different neighborhoods in Miami Dade County to come together and share meaningful dialogue about issues such as diversity, prejudice, school culture, social problems facing teens, and ways to improve our community.

By choosing to participate in MetroTown you are making a decision to be a part of this supportive and inclusive community of young people who dare to imagine a more just and cooperative society.

MetroTown will be held on the campus of St. Thomas University, in Miami Gardens, from June 18th through June 23rd, 2018.

MetroTown Application

If you are human, leave this field blank.

Name of Applicant *

Email *

Home Phone

Cell Phone

Address where applicant receives mail *

City *

State *

Zipcode *

Date of Birth (month/day/year) *

Age applicant will be at MetroTown *

School you will be attending Fall 2018 *

Grade you will be enrolled in Fall 2018

Parent or Guardian Name(s): *

Primary Parent/Guardian Mailing Address (if different from applicant’s address ):

Parent/Guardian City

Parent/Guardian State

Parent/Guardian Zipcode

Parent’s/Guardian’s Phone (Home)

Parent’s/Guardian’s Phone (Work) *

Parent’s/Guardian’s Phone (Cell) *

Does parent/guardian speak English? *

Yes

Primary Parent’s/Guardian’s E - Mail Address: *

What is the language spoken in the home? *

Preferred way to contact parent (select one) *

Gender Identity *

Ethnic/Cultural Backgrouind *

Ethnic/Cultural Background (if selected "Other", please specify)

Race *

Text

Faith Or Religious Affiliation *

Faith or Religious Affiliation (if selected "Other", please specify):

Household Arrangement *

Household Arrangement (if selected "Other", please specify):

Household Income *

School Lunch Program *

Sexual Orientation *

Sexual Orientation (if selected "self-identified", please specify)

Special Needs: Does the applicant have a disability? *

Yes

Special Needs: If yes, what accommodations/modification are required?

Special Needs: Does applicant have any special needs? *

Yes

If applicant has any special needs, please explain:

Are you a Student Voices Panelist? If yes, when were you trained? *

Are you a member of any other school clubs or participate in any school activities or sports? If yes, what clubs/activities/sports? (Include for how long and role/ position)* *

In what other capacities are you involved in your community? (job, religious, political, arts, music, neighborhood, service, etc.)*

Please describe a time when you have experienced or witnessed prejudice, discrimination, or some other “ism” (for example: racism, sexism, ageism, etc.). Provide details including how you felt, what you saw, what you did, and how that event made you see yourself or others in a new light. *

Please tell us about a time when you have taken some sort of action to stop prejudice, discrimination, or some other form of “ism.” If you have not taken an action, describe a time when you wish you had taken an action and why you did not. *

What would you like to get out of your MetroTown experience? *

Please talk about one or two social issues that interest you or you want to know more about. Describe the issue, and tell us why it matters to you. If applicable, also tell us what you have done so far to learn more about it and/or take action to make change. *