Network Point Person Enrollment Form

The Project IMPACT
Certificate Program in Well-Made Leadership

Office of Multicultural Programs and Services
Kansas State University

Revised 8/13/2012

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:                             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.)

Funded by: State of Kansas Juvenile Justice Authority Koch Industries, Inc. Cargill, Inc.