Kansas State University

Revised:  08/08/12

RETURN TO THE  OFFICE OF DIVERSITY
224 Anderson Hall
Kansas State University
Manhattan, KS 66506

Date:                             

Name: 

School/Community Affiliation:                

Target County: Select One Finney Ford Geary Saline Sedgwick Seward Shawnee Wyandotte                       

Case Load:

Gender:        Male        Female 

Race/Ethnicity:

                      White                       Black/African-American

                      Hispanic                   Asian/Pacific Islander

                      American Indian       Multiracial

Mailing Address:

Email Address:                    

Work Phone #:             Cell Phone #:         

I have discussed the Project IMPACT Certificate Program in Well-Made Leadership with project personnel. I agree to partner with the program as a Network Point Person.

(By selecting the "Submit Form" button, you are signing this Agreement electronically.)