Greater Des Moines Conference For Young Men Of Color 2024
10/26/2024
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First Name *
Last Name *
Email *
Phone Number *
Zip Code *
Social Media *
Age *
Ethnicity *
Grade *
School *
Favorite Subject *
Free Lunch? *
Do you have access to Internet? *
Do you have access to Zoom? *
If we could place you in a summer job, what would you want to do? *
What is your super power? *
Through which solution below do you see yourself making the most impact on the world? Choose 1 *
On a scale from 1 to 10, how strongly do you feel you can have an impact on the world, based on your answer to the previous question? *
T-Shirt Size *
Emergency Contact
Who should we call in case of an emergency?
Name *
Relationship *
Email *
Phone Number *
Acknowledgment 

It is important that we always acknowledge the possibility that accidents may happen. In such event that something unfortunate was to happen Hip-Hope Inc. or The Eddie Davis Community Center, shall be held harmless.

Also we need permission to include your child in any Video and or Photo shoots involved with Hip-Hope Inc. activities which would include but is not limited to displaying on the Hip-Hope Inc. Website.


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