NB Program Referral Registration

PROGRAM REFERRAL REGISTRATION FORM

NEW B.O.Y recognizes liability for consequences due to co-mingling of NEW B.O.Y. cadets to foster the full social development possible for each youth. Under Life-coach supervision, cadets will interact with each other in various capacities so that each young person enhances his life-skills to better prepare him to be responsible for his actions and be respectful to women who are a part of his life. If for any reason certain young men cannot interact with each other, the parent/ guardian must inform the NEW B.O.Y. program; thereby avoiding unintended negative consequences among the cadets.

Referral Date

Date

First Name

Last Name

Age

Date Of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Current School

Grade

District

Is there an IEP in place at school

Behavior Plan/504 on file at school

Current Allergies and/or Medications

Parent or Guardian Name

Parent or Guardian Phone

Parent or Guardian Email

example@example.com

Emergency Contact Name

Relationship

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

(Child #1 Name)

(Child #1 Age)

(Child #2 Name)

(Child #2 Age)

Sports/Social Interests

Other Concerns

What would you like for the New B.O.Y. mentor to focus on during his interactions with this young man?

(Parent/Guardian's Signature)

(Date)

Date

(Parent Email)

example@example.com

NEWBOY

Additional Siblings