Ubuntu Cultural Immersion Summer Program Registration Form

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Thank you for your interest in enrolling your child in the first of its kind Cultural Immersion Summer Program. The Program serves to be a unique opportunity for teens to explore and embrace their cultural identity in a positive and supportive environment.

Teens will be engaged in thought provoking and fun-filled activities that will generate conversations and develop belonging and pride in their heritage. We are excited to offer this life changing and empowering program to your child and most importantly having your support in ensuring his/her success.

Once completed we will be following up with further details via email provided.

Program Location: 1145 E Washington St. Phoenix AZ 85034
Date: June 3rd 2024 - June 28th 2024
Days: Monday - Friday
Time: 9am - 3:30pm
Contact Info: saraboselectionsinfo@gmail.com

Program Coordinator: Zoe Sarabo. Kindly text any questions or clarifications to 602-492-6045

Email *

Record my email address with my response

Name of Guardian *

Guardian Email Address *

Guardian Phone Number

Guardian Home Address

Child's First and Last name *

Child's Phone number (if child has a phone)

Child's Date of Birth

YYYY

Gender

Male

Female

Prefer not to say

Clear selection

Child's Address

Child's Ethnicity

African American

Caribbean

African

Other:

Child's First Language

Alternate Emergency Contact.
Please provide Name, Phone Number and Relationship

Person authorized to pick up child.

Person not authorized to pick up child. (Legal paperwork will be requested)

Does your child have any allergies or intolerance to medication, food or any other substance?

Yes

If Yes, list the substance in following question

Clear selection

School Child will be attending August 2024

Grade Child will be in start of August 2024

Please write any siblings' names below: *

Will participant be in need of scholarship support?

Yes, A scholarship will guarantee our participation.

No, Thank you for the offer.

Clear selection

Will there be a need for Early Drop Off and Late Pick Up Services

Yes

Clear selection

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