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IOTA PHI FOUNDATION, INC.
A 501(c)(3) Non-profit Corporation
EIN 23-2907335
United Way Number 1300342
HomeHBCT Application




Iota Phi Foundation

Sylvester Pace Historical Black College Tour

PO Box 99274 Pittsburgh, PA 15233

412.329-8527

 



                          

 


Dear Student:

 

Thank you for your interest in the Annual Sylvester Pace Historical Black College Tour.

 

The Iota Phi Foundation of Pittsburgh is a non-profit corporation that is organized and operated by professional, educated black men who volunteer their time to improve the quality of life of people in the greater Pittsburgh community. Since the tour inception, 900 plus high school juniors from the Pittsburgh area and neighboring counties have participated in visiting at least 15 HBCU’s annually.

 

Students will find out firsthand about the history of black colleges & universities’ rich traditions and college life directly from faculty staff and active students on campus. In addition, students will have an opportunity to visit African American historical sites.  

 

Student must submit the following:

  • High school transcript (minimum 2.5 GPA).
  • A 300 word typed essay about your aspirations beyond high school.
  • A $50 application fee via money order made payable to Iota Phi Foundation.
  • Student must be available for an interview.
  • Letter of recommendation from your teacher, counselor or community leader.

 

Attached is the application for the Historical Black College Tour. Please complete the application packet in its entirety, application fee paid to Iota Phi Foundation and return by the third Friday in November c/o Michael Harrell, Iota Phi Foundation, PO Box 99274 Pittsburgh, PA 15233. The total cost for the tour is $650.00.  Students selected for the tour will be required to participate in a required fund raising activity. Date TBD later.

 

The members of Iota Phi Foundation look forward to meeting those interested in embarking on our annual “Sylvester Pace Historical Black College Tour.” I want to thank you in advance for your continued support of our annual college tour.




Sylvester Pace

     HISTORICAL BLACK COLLEGE TOUR APPLICATION

Return To: c/o Michael Harrell, Iota Phi Foundation PO Box 99274, Pittsburgh, PA 15233

Deadline Date: Third Friday in November, Application Fee: $50.00 Non-Refundable

(Money Order Only made payable to Iota Phi Foundation)



Last Name_____________________________ First Name______________________________ Sex_____

Home Address_____________________________________________________ Apt#________________

City______________________ State_________ Zip code________ Email Address____________________

 

High School presently attending______________________________________________ Grade_________

Address_____________________________________ City_________ State_________ Zip code_________

 

Name of parent or guardian________________________________________________________________

Address if different_______________________________________________________________________

City___________________________________ State_________________ Zip code___________________

Home telephone number_______________________________ Work telephone number________________

 

Emergency contact person_________________________________________________________________

Telephone number_______________________ Relationship to student_____________________________

 

Are you currently involved in after school activities?  If yes, please specify___________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Personal Health History (To be filled out by parent or guardian)________________________________

List any medications to be taken while on the tour: ______________________________________________

General Information:

                                 yes  no                           yes  no                                         yes  no

asthma                     ___/ ___  diabetes         ___/ ___   high blood pressure  ___/___

convulsions/seizures ___/ ___  heart trouble  ___/___    allergies                   ___/___

 

List any physical or behavioral conditions that may affect or limit full participation in strenuous walking tours: _________________________________________________________________________________

Name of primary care physician___________________________________ Phone number_______________

Personal health/accident insurance carrier________________________ Policy No._____________________

Note: Attach a photo copy of your child’s medical card to this application.

Parent Authorization: This health history is correct so far as I know, and the person herein described has permission to participate in all prescribed activities, except as noted by me. In the event of illness or accident in the course of such activity, I request that measures be instituted without delay as the judgment of medical personnel dictates.  Therefore, I grant the program permission to provide any emergency medical services needed if such is necessary.  I understand that this emergency treatment is to be covered by my medical insurance.  It is further understood that this grants permission for the hospital to treat me.

 

Parent or Guardian’s Signature____________________________________________Date____________

 

Subscribed and sworn to before me this ____day of______________, ______  ____________________________________

                                                                                                                  Year                                   Notary Public