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Communiversity Youth Programs Volunteer Application

Please review the entire form before you begin to make sure you have all the necessary information ready. It is recommended that you compose your essay responses prior to starting the form.

All fields in this form are required unless otherwise noted

Personal Information

Name:

Birth Date:

Gender

Male Female

Ethnic Background:
(check all that apply)

White (non-Hispanic) Black (non-Hispanic) American Indian/Alaskan Native Asian/Pacific Islander Hispanic Other:

Contact Information

Local Phone Number:

Local Address:

Street:
City:
State:
ZIP:

Email Address:

Permanent Phone Number if different from local:

Permanent Address if different from local:

Street:
City:
State:
ZIP:

Current Academic Information

Major:
Class:

Cumulative GPA:
Last Semester GPA:

Background

Have you ever been charged with any crime other than a minor traffic violation?

No Yes

If yes, please explain:

Please list any volunteer, employment, and/or personal experiences relevant to the Communiversity volunteer position.

Emergency Contact

In case of an emergency, please contact:

Name:
Relationship:
Home Phone:
Work Phone:

Address:

Street:
City:
State:
ZIP Code:

References

Please list two persons as references (excluding family members). One must have known you at least four years, and the other must be a former teacher, faculty member, work supervisor, or mentor.

Name:
Relationship:

Address:

Street:
City:
State:
ZIP Code:

Years of Association:
Phone:

Name:
Relationship:

Address:

Street:
City:
State:
ZIP Code:

Years of Association:
Phone:

Application Essays

Why does the Communiversity Youth Program interest you? What is your vision for youth in America? How can this vision be accomplished?

By submitting this form, you certify that all statements made on this application are accurage and complete. You understnad this information may be used to conduct a background check to determine your eligibility as a volunteer with the Communiversity Youth Programs. You further understand that any falsification of information may result in immediate dismissal from the program.

The Sonja Haynes Stone Center for Black Culture and History

Campus Box 5250, 150 South Road, Chapel Hill, NC 27599-5250 • Tel (919) 962-9001 • Fax (919) 962-3725
Open Monday to Friday, 8am to 5pm

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