BLACK LIVES MATTER Golf - Junior Mentorship Program (BLMG-JMP)
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Registration Form
Black,Indigenous and People of Colour (BIPOC) youth between the ages of 12-17 free of cost and golf clubs will be provided
Please complete all information below:
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
T-Shirt Size
Small
Medium
Large
X-Large
Gender
E-mail
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How do you Indentify: Select all that apply
Black
Indigenuos
Person of Color
Age
Age 12-17 youth in Nova Scotia
I have my own Clubs
Yes
No
Medical Information
Health Card Number
Age 12-17 youth in Nova Scotia
Does your Child have any medical conditions that we should know about?
Yes
No
Please Specify
Parent Contact Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Alternate contact and phone number
Please enter a valid phone number.
Format: (000) 000-0000.
*I understand that photos of my child may be taken at various BLMG events, and I give permission for those photos of my child to be used on various media platforms including BLMG`s website www.blmgolf.ns.com*
Yes
No
Comments, Questions, or Suggestions
Signature of Parent
Submit
Should be Empty: