Anytown 2025 Delegate Application

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Anytown
Anytown is NCCJ's flagship youth leadership and human relations summer camp. Click here to learn more about Anytown.

To be eligible to attend Anytown as a delegate, you must be a rising high school sophomore, junior, or senior who lives or attends school in North Carolina.
(Exceptions to these rules can be made on a case-by-case basis. Contact Kelly Dawson at kdawson@nccjtriad.org with questions.)

To complete this application, you will need the name, contact information, and job title of a community member willing to support your application.

Should you need assistance completing this application please contact Kelly Dawson at kdawson@nccjtriad.org or 336-272-0359 x 210.
Applicant Information


















(Ex: man, woman, nonbinary, transgender man, transgender woman, etc.)






By checking the text opt-in box you are agreeing to receive periodic SMS and/or MMS message from this organization. Message and data rates may apply. Text HELP for more information. Text STOP to stop receiving messages



Next page:  Parent/Guardian information

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Parent/Guardian Information
Parent /Guardian #1



















By checking the text opt-in box you are agreeing to receive periodic SMS and/or MMS message from this organization. Message and data rates may apply. Text HELP for more information. Text STOP to stop receiving messages

Parent /Guardian #2



















By checking the text opt-in box you are agreeing to receive periodic SMS and/or MMS message from this organization. Message and data rates may apply. Text HELP for more information. Text STOP to stop receiving messages

Additional Emergency Contact 
In the event of an emergency, NCCJ will contact the parent/guardians listed above. If you would like to provide an additional emergency contact, please list that information below. 






Additional Information 
If there is any other parent/guardian information that you think we need to know, please list that here:

Next Page:  Demographic information:

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Demographic Information
To ensure diversity at Anytown, we ask that you please check any/all of the following that apply to you:  (This information is confidential and will be viewed by NCCJ staff only.  It will not be used or disclosed for any other purposes.)











Next Page:  Community member endorsement

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Community Member Support
Anytown challenges students to discuss their experiences with and attitudes about human relations issues. That's why NCCJ asks each student applicant to get support from a community member, such as a teacher, counselor, principal, supervisor, or faith leader. By supporting the student application, the community member is agreeing that the student is physically, emotionally, and mentally capable of participating in Anytown.

Please provide the name of a community member that we can contact for support of your application. 







Next page:  Tuition, fees and tuition assistance

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Tuition, Fees & Tuition Assistance

Cost of Attending
  • The full cost of attending Anytown is $900.
  • $50 of the $900 is a non-refundable registration fee. 

Tuition Refunds from Cancellation/Early Departure

  • A 50% refund of tuition will be made upon written request when a cancellation is made at least three weeks before a session. 
  • A full refund of tuition will be made due to illness. 
  • To receive a refund, submit your request to Alison Whitman Jones at ajones@nccjtriad.org.  
  • No refunds will be given for a delegate who leaves a session early.

 

Tuition Assistance:

  • NCCJ works hard to ensure Anytown delegates include a diverse population. This includes socio-economic diversity. Generous, need-based tuition assistance is available to all applicants. Please do not let your need for assistance discourage you from applying to Anytown.
  • NCCJ will do our best to work with your family to cover the fees that you cannot. We ask that you please only request what you truly need so that we can provide aid to everyone who needs assistance.
  • Please indicate below whether you are applying for tuition assistance and how much of the full cost of attending Anytown ($900) you can pay. 
  • All information provided will be kept confidential.
  • All tuition assistance applicants will receive a statement from NCCJ indicating whether their request for tuition assistance has been accepted or declined.


ex: $25, $100



ex: $25, $100

We accept cash, checks, money orders, and all major credit cards. For credit card payments, please call our office or click here to pay online.


By signing below, I verify that I have thoroughly read the information listed in the tuition, fees and tuition assistance section of this application. I give my permission for the young person named above to apply as a delegate for NCCJ's Anytown 2025 residential program.



Next Page: Bullying Policy

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Anytown Bullying Policy


At Anytown, we have a firm policy against all types of bullying. Everyone in the program is expected to treat each other with respect. This includes delegates (campers), volunteers, and NCCJ staff members. Our Anytown staff has been trained to recognize all incidents of bullying and take them seriously. We promote respectful communication between staff and delegates and work together as a team to ensure that each delegate has a wonderful and safe experience at Anytown.

What is bullying?


Bullying is aggressive behavior that is intentional, is repeated over time, and involves an imbalance of power or strength. Bullying can take on various forms, including:

  •      Physical bullying – when one person engages in physical force against another person, such as by hitting, punching, pushing, kicking, pinching, or restraining another.
  •      Verbal bullying – when someone uses their words to hurt another, such as by belittling or calling another a hurtful name.
  •      Nonverbal or relational bullying – when one person manipulates a relationship or desired relationship to harm another person. This can include social exclusion, friendship manipulation, or gossip. This type of bullying also includes intimidating another person by using gestures.
  •      Hazing – an activity expected of someone joining or participating in a group that humiliates, degrades, abuses, or endangers that person regardless of that person’s willingness to participate.
  •       Sexualized bullying – when bullying involves behaviors that are sexual in nature. Examples of sexualized bullying behaviors include sexting, bullying that involves exposures of private body parts, and verbal bullying involving sexualized language or innuendos.

Anyone who sees an act of bullying, and/or who then encourages it, is engaging in bullying. This policy applies to all employees, contractors, and volunteers.


Bullying may show up as:

  • Teasing
  • Name Calling
  • Excluding Others
  • Rumors
  • Ganging Up
  • Intentionally disrupting programs and activities
  • Mocking or taunting
What's the impact?
The bullying behavior has a negative impact emotionally, spiritually, or physically on the victim. 

Discipline Procedures
If a delegate does not follow Anytown's community agreements, we will take the following action steps as behavior problems progress:
  1. Staff will redirect the delegate to more appropriate behavior. 
  2. If innapropriate behavior continues, the delegate will be reminded of the first warning they received. NCCJ staff will work with the student to decide on appropriate action steps. A phone call home may occur at this point if staff and/or student feel like this is necessary or could be helpful. 
  3. If a delegate's behavior continues, the delegate's parent/guardian will be notified, or the delegate may be dismissed from camp. 
Bullying incidents and action steps will be documented by NCCJ staff. 

If a delegate is participating in bullying activities, the delegate's parent/guardian can be called and asked to pick up their child immediately, regardless of the time of day or day of the week. 

By signing below I acknowledge that I have read, understood, and agree to the bullying policy above. 




Next Page: Delegate and Parent/Guardian Agreements

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For Anytown Participant
I accept my appointment as a delegate to Anytown 2025. I recognize my responsibility to myself, my family and my school or sponsoring agency, and I agree to be the best possible participant in Anytown. I agree to be present for the entire Anytown session, from beginning to end. I have read and understand all of the guidelines of Anytown involving safety, protecting the camp property, and being responsible for my personal behavior, and I agree to respect and honor those guidelines. I also understand that violations of these guidelines may result in my dismissal from the program, and/or may require the involvement of legal authorities. I will respect the rights of others. I consent to random searches by NCCJ staff of my property and, on reasonable suspicion, my person. I understand that non-compliance with this agreement can result in my immediate removal from the Anytown program.

I understand that Anytown is an intensive human relations and leadership program that deals with mature subject matter. I understand that discussion topics may include religious discussions, self-reflection, interpersonal communication, racial identity, racism, sexism, heterosexism, classism, ableism, family issues, institutional and personal power and the cycle of oppression.

I understand that participants and staff often find Anytown to be an emotional experience. Throughout the week, participants may experience confusion, anger, joy, sadness, frustration, hope and other emotions related to challenging issues of bigotry as we learn about the impact discrimination has on us personally and on others. I assure you that I am capable of handling the subject matter and the emotional nature of this program and have no known mental or emotional disorders or sensitivities that would interfere with my participation.

I understand that although NCCJ has taken precautions to provide proper organization, supervision, instruction, and equipment for each activity, it is impossible for NCCJ to guarantee absolute safety and security. I also understand that each participant shares the responsibility for safety during all activities and the security of his/her own belongings, and I assume that responsibility for myself. I waive any claim that may arise against NCCJ and/or its Board of Directors, employees, agents, volunteers, or lessors including those claims that may arise from the negligence of NCCJ its Board of Directors, employees, agents, lessors or volunteers. 

By signing below, I verify that I have thoroughly read and agree to the statement above.


For Parent/Guardian
For Parent/Guardian

I give permission for my child (whose signature appears above) to attend Anytown. To the best of my knowledge, my child/the child in my care has no known mental or emotional disorders or sensitivities that would interfere with his/her participation and that my child/the child in my care is capable of handling the subject matter and the emotional nature of this program. Participants will be asked to complete a series of written evaluations during and after the program. I hereby grant permission for my child to complete evaluation questionnaires.

If NCCJ Staff must send my child/the child in my care home for any reason, I agree to pick him/her up within five hours of the Director’s call. I understand that I may be called at any time of the night or day to arrange for my child’s transportation home and that I will be responsible for all costs associated with such transportation.

If my child’s/the child in my care’s medical information should change prior to Anytown, I will notify NCCJ of any new conditions, medications, limitations, etc.

As the parent/guardian of a participant of Anytown, I agree to defend, indemnify, and hold harmless NCCJ and/or its Board of Directors, employees, agents, volunteers, or lessors from and against all claims, losses, costs, and expenses (including attorneys' fees) arising out of my child/the child in my care’s participation in the Anytown or any other NCCJ program. 

By signing below I have read and understood all the registration documents required for my child’s/the child in my care’s participation in the Anytown program. I stand behind and support my child/the child in my care in their pursuit of personal growth and leadership development. I recognize my responsibility to my child and the rest of the Anytown community.


Next Page: Photo Release

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Photo Release
I am the parent/legal guardian of the student who will be participating in activities sponsored by the NCCJ including Anytown and any other follow-up activities. I understand that my child/the child in my care, alone or with other participants and/or NCCJ staff, volunteers or representatives, may be interviewed, photographed, recorded on film, audio tape, videocassette, or other visual and sound computerized, telephonic, voice-mail or tape media (“photographs and/or sound/image recordings”) and/or may provide written or oral statements to NCCJ and/or others approved by NCCJ.

I hereby consent to the foregoing and grant permission, without reservation, to NCCJ and/or those approved by NCCJ to generate, prepare, advertise, describe and/or publicize NCCJ and its work, good will, public education and/or fundraising activities, disseminate, otherwise use and comment upon the photographs and/or sound/image recordings as they may determine, without review by me or my child/the child in my care and without financial or other obligation of any nature to me or my child/the child in my care.  I consent that my child/the child in my care may be identified by name, age, race, school of attendance, city of residence, or program of participation as these companies and/or those approved by these companies may determine.  Uses may include, but are not limited to, promotional videos, fundraising appeals, website content, and news coverage.

I release NCCJ its officers, Board of Directors, volunteers, agents, employees and licensees from all claims that I or my child/the child in my care may have, or might have, for any cause of action arising out of the taking and/or use of the photographs and/or sound/image recordings as set forth herein.  This consent and release shall continue in effect, without a limitation of time.




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COVID 19 Liability Waiver
I acknowledge the contagious nature of COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.   I further acknowledge that North Carolina for Community and Justice, Inc. (NCCJ) has put in place preventative measures to reduce the spread of COVID-19 and that NCCJ cannot guarantee that my child/the child in my care  will not become exposed to or infected with the Covid-19.  I understand that the risk of becoming exposed to and/or infected by COVID-19 may result from the actions, omissions or negligence of myself and others, including, but not limited to, NCCJ Staff, program participants and their families.

I acknowledge that my child/the child in my care, whose signature appears below, is voluntarily participating in programming provided by NCCJ and acknowledge that this increases my child’s/ the child in my care’s risk to exposure to COVID-19. I acknowledge that my child/the child in my care and I must comply with all set procedures to reduce the spread while attending NCCJ programming. I hereby release and agree to hold North Carolina for Community and Justice, Inc. harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act by NCCJ, or that may otherwise arise in any way in connection with any services received from NCCJ. I understand that this release discharges the National Conference for Community and Justice from any liability or claim that I, my heirs, or any personal representatives may have against NCCJ with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from NCCJ. This liability waiver and release extends to North Carolina for Community and Justice together with all owners, partners, employees, and program volunteers.