Kansas State University

RETURN TO THE OFFICE OF DIVERSITY

224 Anderson Hall

Kansas State University

Manhattan, KS 66506

If you are a student living in one of the target counties, you need to discuss your participation in the program with your parent(s) or guardian(s).  

If they agree to  your participation, you will need to fill out the Participant Enrollment Card or the Participant Online Enrollment Form, and we will get back to you on next steps.  

Date:                             

Name:

School:                

Classification:        Freshman     Sophomore     Junior     Senior 

Career Interest:

Age:        Gender:     Male        Female 

Race/Ethnicity:

                        White                        Black/African-American

                        Hispanic                     Asian/Pacific Islander

                        American Indian         Multiracial

Mailing Address:    

Target County:  Select One Finney Ford Geary Saline Sedgwick Seward Shawnee Wyandotte                            Network Point Person (if any):

Home Phone #:                      Cell Phone #:

Email Address:      

Parent/Guardian:                    Relationship:

Parent/Guardian:                     Relationship:

Parent/Guardian Phone #:           

How did you learn about the program?  (For example, Neighborhood Youth Specialist, Network Point Person, campus event, school counselor, friend, etc.)