Springfield Urban League, Inc. Camp Nkiru Enrollment Form

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Welcome to Camp Nkiru!

The purpose of Camp Nkiru is to provide community youth with new ideas and opportunities that will empower them to make positive and life affirming choices that will improve their lives, their families’ lives, and their community.

Use this form to indicate interest in signing up a student for our Camp Nkiru program! A member of our staff will contact you if the child is selected.

For any questions, comments or concerns please email jwoolfolk@springfieldul.org or call our main office 217-789-0830.

Please submit multiple forms for multiple children.

Email *

Student's Full Name (First, Last) *

Student's Birthdate *

YYYY

Student's Age *

Student's Race/ Ethnicity (Check All That Apply) *

American Indian or Alaska Native

Native Hawaiian or Pacific Islander

Asian

Black or African American

Hispanic/Latino

White

Other:

Required

Parent/Guardian Full Name (First, Last) *

Mailing Address for Household (Please include Address, City, State and Zip Code) *

Relationship to Child *

Parent

Grandparent

Other:

Are you the child's legal guardian? *

Yes

Emergency Contact for Student (Please include full name and phone number, may add up to 3 individuals) *

Student's Currently Grade Level (2023-2024 School Year) *

Is your student currently enrolled in an Urban League program? If so, which? *

21st Century

Project Ready Mentor

My Student is not enrolled in an Urban League Program

Other:

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