Revised NTF Form

OMB Control No. 1024-0232

Expires 12/31/2006

National Park Service

National Underground Railroad Network to Freedom

GENERAL INFORMATION

Type (pick one): ___ Site ___ Facility ___ Program

Name:

Address:

City, State, Zip:

County: Congressional District:

Physical Location of Site/facility (if different):

___ Address not for publication?

Date Submitted:

Summary: Describe in 200 words or less, the significance to the Underground Railroad, of the site, program, or facility nominated for inclusion in the Network.

FOR NATIONAL PARK SERVICE USE ONLY

I hereby certify that this ___ site ___ facility ___ program is included in the Network to Freedom.

__________________________________ _________________

Signature of certifying official/Title Date

Owner/Manager (Share contact information ___Y ___ N)

Name:

Address:

City, State, Zip:

Phone: Fax: E-mail:

Owner/Manager (Share contact information ___Y ___ N)

Name:

Address:

City, State, Zip:

Phone: Fax: E-mail:

Owner/Manager (Share contact information___Y ___ N)

Name:

Address:

City, State, Zip:

Phone: Fax: E-mail:

Application Preparer (Enter only if different from contact above.) (Share contact information ___Y ___ N)

Name:

Address:

City, State, Zip:

Phone: Fax: E-mail:

Privacy Information: The Network to Freedom was established, in part, to facilitate sharing of information among those interested in the Underground Railroad. Putting people in contact with others who are researching related topics, historic events, or individuals or who may have technical expertise or resources to assist with projects is one of the most effective means of advancing Underground Railroad commemoration and preservation. Privacy laws designed to protect individual contact information (i.e., home or personal addresses, telephone numbers, fax numbers, or e-mail addresses), may prevent NPS from making these connections. If you are willing to be contacted by others working on Underground Railroad activities and to receive mailings about Underground Railroad-related events, please add a statement to your letter of consent indicating what information you are willing to share.

Paperwork Reduction Act Statement: This information is being collected for applications to the National Park Service’s National Underground Railroad Network to Freedom to nominate properties, facilities, and programs to the Network to Freedom. A Federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Response to this request is required for inclusion in the Network to Freedom in accordance with the National Underground Railroad Network to Freedom Act (P.L. 105-203).

Estimated Burden Statement: Public reporting burden for this form is estimated to average 15 hours per response including time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding this burden estimate or any aspect of this form to the National Coordinator, National Underground Railroad Network to Freedom, NPS, 601 Riverfront Drive, Omaha, Nebraska 68102.

SITES:

In addition to the responses to each question, applications must also include the following attachments:

1. Letters of consent from all property owners for inclusion in the Network to Freedom (see sample)

2. Text and photographs of all site markers

3. Photographs illustrating the current appearance and condition of the site being nominated

4. Maps showing the location of the site

S1. Site type:

___ Building ___ Object ___ District (neighborhood)

___ Structure ___ Landscape/natural feature ___ Archeological site

___ Other (describe):

S2. Is the site listed in the National Register of Historic Places? ___Y ___ N

What is the listing name:

S3. Ownership of site:

___ Private ___ Private, non-profit (501c3) ___ Multiple ownership

___ Public, local government ___ Public, State government ___ Public, Federal government

S4a. In a narrative form, describe the site’s association and significance to the Underground Railroad. Provide citations. Supplemental chronologies are encouraged.

S4b. Type(s) of Underground Railroad Association (select all that apply)

___ Station ___ Assoc. w/ prominent person ___ Legal challenge ___ Maroon community

___ Escape ___ Rescue ___ Kidnapping ___ Transportation route

___ Destination ___ Church w/active congregation ___ Cemetery ___ Military site

___ Commemorative site/monument ___ Other (describe):

S5. Provide a history of the site since its time of significance to the Underground Railroad, including physical changes, changes in ownership or use of the building(s) and site.

S6. Describe current educational programs, tours, markers, signs, brochures, site bulletins, or plaques at the site. Include text and photographs of markers.

S7. Identify historical sources of information. Include a bibliography.

S8. Describe any other local, State, or Federal historic designation, records, signage, or plaques the site has.

S9. Is the site open to the public, and under what conditions?

S10. Describe the nature and objectives of any partnerships that have contributed to the documentation, preservation, commemoration, or interpretation of the site.

S11. Additional data or comments. (Optional)

FACILITIES

In addition to the responses to each question, applications must also include a letter of consent for inclusion in the Network to Freedom from the facility owner or manager.

F1. Facility type:

___ Archive ___ Library ___ Museum ___ Research Center

___ Other (describe):

F2. Provide a general description of the facility and its purpose or mission.

F3. Identify and describe the holdings or collections, detailing their significance to the Underground Railroad.

F4. List or catalog the Underground Railroad or slavery-related collections or materials the facility has.

F5. Identify and describe the types of documents the facility has to identify the provenance of its collections.

F6. Identify and describe the types of guides or indexes that are available for the facility’s collections.

F7. Describe the facility’s management and staff, and levels of training or certifications.

F8. Describe the types of publications, reports, or services the facility performs or produces.

F9. Identify and describe the conditions of public access to the facility, including handicapped access.

F10. Describe visitation workload at the facility.

F11. Describe the facility’s traveling exhibit, interlibrary-loan, and photocopying or duplication policies and capability.

F12. Describe the nature and objectives of any partnerships that have contributed to the operation of the facility.

F13. Additional data or comments. (Optional)

EDUCATIONAL AND INTERPRETIVE PROGRAMS

In addition to each question, applications must also include the following attachments:

1. Letters of support from people consulted in the development of the interpretive program describing their role as advisors.

2. An example of an audience feedback card or questionnaire or other audience feedback mechanism.

3. A letter of consent for inclusion in the Network to Freedom from the owner or manager of the program.

4. A video of the program or a sample of the program for evaluation purposes. See instructions for use policy. (Optional but recommended.)

P1. Program type:

___Interpretive program ___ Tour ___Education program ___Dramatic performance, theater

___ Living history ___Commemorative or cultural center

___Other (describe):

P2. Describe the Underground Railroad theme or message of the program, and how it is conveyed to the audience.

P3. Describe the consultation and planning process through which the program’s themes were identified. Include subject matter experts.

P4. Identify historical sources of information and describe how they were used to develop the program. Include a bibliography.

P5. Describe the educational objectives of the program, tour, or performance.

P6. For whom is the program intended?

P7. Describe the geographic area of program presentation or activity.

P8. Describe how the program is evaluated.

P9. How long has the program existed and what are the future plans for the program.

P10. Describe the program’s management and staff, and levels of training or certification.

P11. Describe the nature and objectives of any partnerships that have contributed to the program.

P12. Additional data or comments. (Optional)

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