Saturday Academy Registration

EPIC REGISTRATION

Saturday Academy
CHILD INFORMATION:
Child Name*

First NameLast Name
Birth Date*

MonthDayYear
MaleFemale
Grade*
Name of School*
Youth SmallYouth MediumYouth LargeYouth XLAdult SmallAdult MediumAdult LargeAdult XLAdult XXLOther
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
E-mail*
Allergies/Medical Concerns
What skills & resources are you looking for you and/or your child to receive from this program.
I do hereby grant permission to 100 Black Men of Greater Mobile to use the image of my child(ren), such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the 100 Black Men of Greater Mobile’s website.
I do hereby freely and voluntarily give my full permission and consent for my child(ren) to participate in Saturday Academy which will be held during the 2020-2021 School Year. I/we grant the 100 Black Men of Greater Mobile, Inc., permission to request quarterly data that will be used to track and assist students to improve academics, attendance, and behavior.
Signature*
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EPIC REGISTRATION