Yuba College Umoja Sojourners
lack to School Day
Application for Grades 3 - 8
Event Date: Wednesday, April 8, 2020
Parent’s Name: __________________________________________
Address: _________________________________________________________
City/State/Zip _________________________________________________________
E-mail: _________________________________ Phone #: _______________________
Emergency Contact Person (not yourself): ___________________________________________
Emergency Contact’s Phone #:_______________________________________________
Child’s name: _________________________________________ Child’s Date of Birth: _________________
Child’s Street Address City State Zip Code
Gender: Male Female
Grade level: 3rd 4th
5th 6th
7th 8th
Name of Child’s School of Attendance: ________________________________________
Child’s T-shirt Size: ____________________________
I understand that if my child participates in the Yuba College Umoja Program’s Black to School Day,
transportation to and from the event is my responsibility. My child, ________________________________,
has my permission to participate in the event at Yuba College on Wednesday, April 8, 2020.
Parent’s signature ______________________________________________ Date ________________
Event Application due by:
Wednesday, March 18, 2020
Submit Application to: Yuba College c/o Valerie Harris
2088 North Beale Road
Marysville CA 95901
Event Application due by: Wednesday, March 18, 2020
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